THE  LIBRARY 
OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


THE 


PATHOLOGY    OF    THE    EYE 


BY 

J.     HERBERT     PARSONS 

B.S.,  D.SC.(LOND.),  F.R.C.S.(ENG.) 

ASSISTANT    OPHTHALMIC    SURGEON,    UNIVERSITY  COLLEGE    HOSPITAL; 

CURATOR  AND  PATHOLOGIST,   ROYAL  LONDON    (MOORFIELDS)  OPHTHALMIC  HOSPITAL; 
LECTURER  ON  PHYSIOLOGICAL  OPTICS,  UNIVERSITY  COLLEGE,  LONDON 


VOLUME   I 
HISTOLOGY.— PART    I 


NEW    YORK 

G.    P.    PUTNAM'S    SONS 

LONDON  :  HODDER  AND  STOUGHTON 
1904 


PRINTED   BY   ADLARD   AND   SON, 
LONDON   AND    DORKING, 

KNGLAND. 


100 


/./ 

PREFATORY     NOTE 

\|O  complete  monograph  on  the  Pathology  of  the  Eye  has  yet  been 
written  in  any  language.  Various  attempts  have  been  made 
from  time  to  time  to  describe  and  illustrate  the  chief  facts  of  the 
pathological  histology  by  Wedl  (1860),  O.  Becker  (1874),  Pagen- 
stecher  &  Genth  (1878),  Alt  (1880),  Wedl  &  Bock  (1886),  Greeff  (1902), 
Ginsberg  (1903),  and  others.  All  of  these,  with*  the  exception  of 
Ginsberg's  Manual  and  the  incomplete  work  of  Greeff,  are  inadequate 
and  out  of  date ;  and  even  the  latter  works  are  not  available  for  all 
English-speaking  ophthalmologists. 

The  object  of  this  treatise  is  to  give  as  complete  an  account  of  the 
Pathology  of  the  Eye  as  is  possible  in  the  present  state  of  our  know- 
ledge. It  may  be  reasonably  asserted  that  the  time  is  not  ripe  for 
such  a  work,  and  as  far  as  dogmatic  finality  is  concerned  this  is  true 
There  are  few,  however,  who  will  not  admit  the  urgent  need  of  gather- 
ing together  the  grains  of  knowledge  which  we  possess,  and  winnowing 
them  of  the  chaff  of  futile  conjecture  and  discredited  theory. 

It  must  be  admitted  with  regret  that  few  of  the  problems  before  us 
have  been  solved.  I  shall  therefore  endeavour  to  set  forth  the  facts 
which  have  been  discovered,  and  which  have  been  recorded  in  the 
various  European  and  American  scientific  journals.  The  various 
theories  based  upon  these  facts  will  be  reviewed  and  weighed,  with 
the  object  of  determining  their  relative  value,  and  of  arriving  at  the 
best  working  hypotheses  for  directing  future  research. 

It  is  not  to  be  expected  that  my  deductions  will  meet  with  un- 
qualified approval.  I  shall  be  satisfied  if  the  facts,  and  the  theories 


vi  PREFATORY    NOTE 

founded  upon  them,  are  accurately  reproduced,  so  that  future  workers 
may  find  a  safe  foundation  prepared  upon  which  to  build. 

The  work  will  be  divided  into  four  volumes,  the  first  two  dealing 
with  the  Pathological  Histology  of  the  Eye,  the  last  two  with  the 
General  Pathology  of  the  Eye. 

In  Volumes  I  and  II  the  parts  of  the  eye  and  its  annexes  will  be 
taken  seriatim,  and  the  histology  of  the  various  morbid  conditions 
described. 

In  Volumes  III  and  IV  the  diseases  which  affect  the  eye  as  a  whole 
will  be  discussed,  and  an  endeavour  will  be  made  to  trace  them  to 
their  ultimate  causes.  They  will  therefore  include  such  conditions  as 
glaucoma,  sympathetic  ophthalmia,  congenital  malformations,  etc. 
The  microscopic  features  of  these  conditions  will  be  more  conveniently 
dealt  with  in  immediate  relationship  with  them. 


PREFACE    TO    VOLUME    I 

n^HIS  volume  includes  the  Pathological  Histology  of  the  Lids, 
Conjunctiva,  Cornea,  Sclerotic,  Iris  and  Anterior  Chamber,  and 
Ciliary  Body,  together  with  the  Bacteriology  of  the  Conjunctiva. 
The  Normal  Histology  of  the  parts  is  briefly  related,  no  attempt 
being  made  to  give  an  exhaustive  description.  Only  those  features 
which  have  a  special  bearing  upon  pathology  are  more  fully  dealt 
with  ;  these  are  often  inadequately  discussed  in  the  ordinary  text- 
books of  normal  histology. 

All  the  new  illustrations  are  from  photographs,  which  have  not 
been  touched  up  in  any  way.  I  am  of  the  opinion  that  for  elementary 
teaching  good  drawings  are  superior  to  photographic  reproductions, 
much  detail  being  obscured  in  reproduction  by  half-tone  blocks.  In 
an  advanced  work  of  this  kind,  however,  a  good  knowledge  of  normal 
and  general  pathological  histology  is  taken  for  granted,  and  absolute 
fidelity  is  of  prime  importance.  It  is  above  all  things  essential  that 
the  text-book  shall  subserve,  and  not  replace,  work  in  the  laboratory. 

I  am  greatly  indebted  to  the  recent  books  of  Greeff  and  Ginsberg 
in  preparing  this  volume.  I  have  made  a  point,  however,  of  going 
to  original  sources  for  information  ;  but  the  arduous  task  of  dis- 
covering references  has  been  much  facilitated  by  these  works. 

I  am  also  under  a  deep  obligation  to  the  Staff  of  the  Royal 
London  (Moorfields)  Ophthalmic  Hospital :  without  their  assistance 
the  work  could  never  have  been  attempted.  I  have  had  every 
opportunity  of  utilising  the  valuable  pathological  material  which 


viii  PREFACE 

has  come  immediately  under  in)-  notice  as  Pathologist,  as  well  as 
that  which  has  accumulated  under  the  supervision  of  my  predecessors. 

I  am  further  indebted  to  the  Ophthalmological  Society  of  the 
United  Kingdom  for  permission  to  reproduce  illustrations  from  their 
'  Transactions.' 

Professor  Fuchs  has  kindly  sent  me  from  time  to  time  specimens 
from  his  valuable  collection.  Some  of  these  I  have  photographed 
and  reproduced. 

All  the  material  which  I  have  borrowed  from  others  has  been 
acknowledged  in  the  text ;  any  omissions  in  this  respect  have  been 
unintentional.  For  the  remainder  I  am  alone  responsible. 

Mr.  W.  I.  Hancock,  F.R.C.S.,  has  kindly  assisted  me  in  revising 
the  proof  sheets. 

J.    HERBERT   PARSONS. 


CONTENTS     OF     VOLUME    I 


HISTOLOGY.— PART   I 


CHAPTER  I 
THE    LIDS   . 


PAGE 
I 26 


The  Normal  Lids  .       i 

Inflammation    ...       4 

BLEPHARITIS        .         .  -4 

SYPHILIS  .  .  . 
LUPUS  .  .  .  .  .6 
LEPROSY  .  .  .  .  .7 
RINGWORM  AND  FAVUS  .  .  8 
XANTHELASMA  OR  XANTHOMA  .  9 
INFLAMMATION  OF  THE  GLANDS  OF 

THE    LlDS HORDEOLUM   EX- 

TERNUM  AND  INTERNUM  ;  CHA- 
•LAZION    .         .         .         .         .II 

Hypertophic  and  Atrophic 
Conditions      .         .         .12 

HYPERTROPHIC      CONDITIONS  — 
ELEPHANTIASIS       LYMPHANGI- 
OIDES  AND  ARABUM  ;  CHRONIC 
(EDEMA  ;  ELEPHANTIASIS  NEU- 
ROMATODES;  MYXO2DEMA         .     14 

ATROPHIC    CONDITIONS — SENILE 
ATROPHY  ;  BLEPHAROCHALASIS     14 


Tumours    .         .         .         -15 

MOLLUSCUM  CONTAGIOSUM  .  15 

VERRUCA    .         .         .         .         .16 
CORNU  CUTANEUM       .         .  1 6 

FIBROMA     .         .         .         .         -17 
LIPOMA        .         .         .         .         .18 
ANGIOMA — HJEMANGIOMA      LYM- 
PHANGIOMA      .         .         .         .18 

LYMPHOMA 18 

SARCOMA     ...         .         .  19 

ENDOTHELIOMA  .         .         .         .20 
EPITHELIOMA       .         .         .         .21 
RODENT  ULCER  .         .        .        .22 
TUMOURS  OF  THE  GLANDS  OF  THE 
LIDS  —  MILIUM  ;     SEBACEOUS 
CYSTS  ;     CYSTS      OF     MOLL'S 
GLANDS  ;  CYSTS  OF  THE  MEI- 
BOMIAN    GLANDS  ;    ADENOMA  ; 
SYRINGO-ADENOMA  ;        CARCI- 
NOMA      .         .         .         .         .24 
CONGENITAL  TUMOURS  2& 


CONTENTS 


CHAPTER   II 
THE    CONJUNCTIVA. 


PAGE 
30—147 


The  Normal  Conjunctiva     30 

The   Bacteriology  of   the 

Conjunctiva  .  .     35 

THE  NORMAL  CONJUNCTIVA  .  35 
CONJUNCTIVITIS  .  -37 

STAPHYLOCOCCI   .        .  .     38 

STREPTOCOCCI      .         .  .     38 

THE  PNEUMOCOCCUS  (FRANKEL — 

WEICHSELBAUM)  .  .  -39 
THE  GONOCOCCUS  (NEISSER)  .  41 
THE  KOCH-WEEKS  BACILLUS  .  44 
THE  MORAX-AXENFELD  DIPLO- 

BACILLUS         .        .  .     47 

THE       DIPHTHERIA       BACILLUS 

(KLEBS-LOFFLER)  .  .  -49 
THE  XEROSIS  BACILLUS  (Kuscn- 

BERT— NEISSER)      .        .        -51 
OTHER     MICRO-ORGANISMS — Ba- 
cillus coli  communis ;    Bacillus 
influenza  (PFEIFFER)  ;  Bacillus 
pneumonia  (FRIEDLANDER)       .     54 

Inflammation    .         .         -54 

CONJUNCTIVITIS  IN  GENERAL  .  54 
MEMBRANOUS  CONJUNCTIVITIS  .  58 
TRACHOMA  .  .  .  .  -59 
FOLLICULAR  CONJUNCTIVITIS  .  74 
PLYCTENULAR  CONJUNCTIVITIS  .  76 

SYPHILIS 78 

TUBERCLE 79 

LEPROSY 84 

OPHTHALMIA  NODOSA  .     84 

SPRING  CATARRH         .         .         .86 

PEMPHIGUS 89 

CONJUNCTIVITIS  PETRIFICANS       .     92 

Degenerations  .         .         -93 

CONCRETIONS      .        .        .        -93 


Degenerations — continued 

HYALINE,    COLLOID,    AND    AMY- 
LOID DEGENERATION        .         .     96 
XEROSIS      .         .         .         .         .102 
PINGUECULA        .         .         .         .104 
PTERYGIUM          .         .         .         .106 

Pigmentation    .         .         .no 

ARGYROSIS  .         .         .         .         .   no 

Cysts .  .in 

TRAUMATIC  .  .  .  .112 

RETENTION  .  .  .  .112 

LYMPHATIC.  .  .  .  .   115 

PSEUDO-CYSTS  .  .  .  .116 

PARASITIC   .  .  .  .116 

CONGENITAL  .  .  .  .   1 1 7 

Tumours    .         .  .   117 

POLYPUS 117 

PAPILLOMA 118 

SIMPLE  GRANULOMA   .  .119 

LYMPHOMA .         .         .         .         .121 
FIBROMA     .         .         .         .         .122 
H/EMANGIOMA     .         .         .         -123 
LYMPHANGIOMA  .         .         .         -125 
CONGENITAL  TUMOURS — N^EVUS, 
127  ;     EPITHELIAL     PLAQUES, 
130;  DERMOID,   132;   DERMO- 
LIPOMA,  135  ;  OSTEOMA  .        -137 
ADENOMA    .         .         .         .         -138 
SARCOMA     .         .         .         .         -138 
EPITHELIOMA       .         .         .         .141 

The  Caruncle    .         .         .146 

INFLAMMATION    .         .         .         .146 
TUMOURS    .        .        .        .         .146 


CONTENTS 


XI 


The  Normal  Cornea 

Wounds 

UNCOMPLICATED  . 
COMPLICATED 

Abrasions  .         . 
Anterior  Staphyloma 

Keratectasia 
Conical  Cornea 

(Edema 

Striate  Opacity 
Filamentary  Keratitis     .   183 

Inflammation    . 

KERATITIS  IN  GENERAL 

PHLYCTENULAR  KERATITIS 

INTERSTITIAL  KERATITIS 

PANNUS 

SYPHILIS     . 

TUBERCLE  . 

LEPROSY 

SUPERFICIAL  PUNCTATE  KERA- 
TITIS ..... 

SCLEROSING  KERATITIS 

PURULENT  KERATITIS 

HYPOPYON  ULCER 

MYCOTIC  KERATITIS    . 

PERIPHERAL  ANNULAR  INFILTRA- 
TION   217 

MARGINAL  ULCER       .         .         .220 

ATHEROMATOUS   ULCER      .         .221 

MOOREN'S  ULCER  .  222 


CHAPTER    III 

PAGE 

THE    CORNEA         .         .                   148—265 

.   148 

Degenerations  . 

225 

DEGENERATIVE  CHANGES  IN  THE 

EPITHELIUM    .  -      . 

225 

•  iS1 

HYALINE  DEPOSITS  IN  BOWMAN'S 

.   156 

MEMBRANE      .... 

228 

.   166 

HYALINE     DEPOSITS      IN     DES- 

CEMET'S  MEMBRANE 

229 

.   1  68 

ARCUS  SENILIS    .... 

230 

FATTY    INFILTRATION    AND    DE- 

•  173 

GENERATION     .... 

237 

•   174 

HYALINE,    COLLOID,   AND    AMY- 

LOID DEGENERATION 

237 

•   175 

CALCAREOUS  DEGENERATION 

241 

BAND-SHAPED  OPACITY 

243 

•   i79 

NODULAR  OPACITY 

245 

RETICULAR  OPACITY  . 

247 

.   183 

o 

PERIPHERAL       SCLEROSIS       AND 

•    185 

ATROPHY          .... 

247 

.    185 

Pigmentation    . 

249 

.    190 

.    191 

BLOOD-STAINING  .... 

249 

194 

METALS 

253 

•    -^99 

TATOOING   .        .        .        . 

253 

201 
202 

202 
203 
208 
215 


Cysts . 


Tumours    . 


253 


•  256 


PAPILLOMA        AND        CORNEAL 

"HORN  "          ....  256 
FIBROMA     .         .         .  -257 

MYXOMA     ...  •  258 

TERATOID  TUMOURS  .         .         .  258 
SARCOMA  AND  ENDOTHELIOMA    .  259 
EPITHELIOMA      ....  262 
GENERAL   REMARKS   UPON   COR- 
NEAL TUMOURS       .        .        .264 


XII 


CONTENTS 


CHAPTER   IV 


THE   SCLEROTIC     . 

The  Normal  Sclerotic      ;   266  Inflammation — continued. 

TUBERCLE  . 


PACK 
266  —  281 


Wounds  and  Injuries 

Inflammation     . 

EPISCLERITIS 

SCLERITIS    .... 

ANNULAR  SCLERITIS    . 

PURULENT  SCLERITIS  . 

SYPHILIS 


267      LEPROSY 


270 

Degenerations  . 

•   279 

270 

Cysts  . 

•  279 

271 

273 

Tumours    . 

.  280 

277 

BENIGN 

.   280 

278  , 

MALIGNANT 

.  281 

CHAPTER   V 


THE  IRIS  AND  ANTERIOR  CHAMBER  282-333 


The     Normal      Iris      and 
Anterior  Chamber         .  282 


Wounds     . 

Inflammation    . 

ACUTE  IRITIS 
CHRONIC  IRITIS  . 
NODULAR  IRITIS 
PURULENT  IRITIS 
SYPHILIS      . 
TUBERCLE  . 
LEPROSY 

Degenerations  . 


.  286 

.  286 

.  286 
.  291 
.  292 

•  293 

•  294 

•  295 

•  299 

•  3°° 

•  3°° 


ATROPHY    .         . 
CALCAREOUS  DEGENERATION  AND 
OSSIFICATION  ....  304 

The  Angle  of  the  Anterior 
Chamber         .         .         .  304 


RETINAL    EPI- 


Cysts . 

IMPLANTATION     . 
RETENTION 
CONGENITAL 
CYSTS    OF    THE 

THELIUM  . 

PARASITIC   . 
COMPLEX  CYSTS. 


Tumours  of  the  Iris 

N^EVUS,  MELANOMA     . 
ANGIOMA     .... 
MYOMA        .... 
SARCOMA     .... 
CARCINOMA 


311 
312 


321 
321 

322 

322 

325 
326 
326 
329 


Tumours  of  the  Anterior 
Chamber         .         .         -331 

ENDOTHELIOMA  .         .         .         -331 
SECONDARY  GROWTHS          .         -332 


Xlll 


CHAPTER   VI 
THE    CILIARY    BODY 


PAGE 

334—373 


The  Normal  Ciliary  Body  334 
Wounds      ....  336 

Inflammation    .         .         .  336 

ACUTE  AND  SUPPURATIVE  .  .  336 
CHRONIC  .....  349 
SYMPATHETIC  .  .  -353 

SYPHILIS  .....  354 
TUBERCLE  .....  356 
LEPROSY  .  .  .  .  356 

Degenerations  .         .         -357 
SENILE  DEGENERATION        .         -357 


Degenerations — continued 

ATROPHY  .  .  .  .  -357 
CALCIFICATION  AND  OSSIFICATION  357 

Cysts.  .  358 

Tumours  .         .         .  359 

EPITHELIAL  HYPERPLASIA  .  .  359 
ADENOMA  .....  360 
CARCINOMA  .  .  -361 

GLIOMA 363 

ENDOTHELIOMA  ....  363 
MYOMA  AND  MYO-SARCOMA  364 

SARCOMA     .....  365 


ABBREVIATIONS 

A.  d'O. — Archives  d'Ophthalmologie. 

A.  f.  A. — Knapp  and  Schweigger's  Archiv  fur  Augenheilkunde.  (Articles 
in  A.  f.  A.  are  often  translated  or  abstracted  in  A.  of  O.,  and 
vice  versa  ;  the  reference  is  usually  given  to  one  only.) 

A.  f.  O. — v.  Graefe's  Archiv  fur  Ophthalmologie. 

A.  of  O. — Knapp's  Archives  of  Ophthalmology. 

B.  d.  o.  G. — Bericht  der  ophthalmologische  Gesellschaft  zu  Heidelberg.    (The 

earlier  reports  are  contained  in  K.  M.  f.  A.) 

B.  z.  A. — Deutschmann's  Beitrage  zur  Augenheilkunde.     (The  reference  is 

given  to  the  part  [Heft],  not  to  the  volume.) 

C.  f.  A.— Hirschberg's  Centrablatt  fur  praktische  Augenheilkunde. 

G.-S. — Graefe-Saemisch,  Handbuch  der  gesamten  Augenheilkunde.  (The 
date  determines  the  edition:  ist  edition,  1874 — 1877;  2nd 
edition,  1898 —  .) 

K.  M.  f.  A. — Zehender's  Klinische  Monatsblatter  fiir  Augenheilkunde. 

R.  L.  O.  H.  Rep. — Royal  London  Ophthalmic  Hospital  Reports. 

T.  Am.  O.  S. — Transactions  of  the  American  Ophthalmological  Society. 

T.  O.  S. — Transactions  of  the  Ophthalmological  Society,  of  the  United 
Kingdom. 

Z.  f.  A. — Zeitschrift  fiir  Augenheilkunde. 

*. — The  most  important  articles  are  marked  with  an  asterisk  (*). 


CHAPTER    I 
THE     LID5 


THE  lids  are  covered  anteriorly  by  skin  and  posteriorly  by  mucous 
membrane  (conjunctiva  tarsi) ;  they  end  in  a  free  edge  (margo  inter- 
marginalis)  about  3  mm.  broad.  The  substance  of  the  lids  consists  of 
muscles,  glands,  blood-vessels,  and  nerves,  all  bound  together  by  con- 
nective tissue,  which  is  particularly  dense  at  the  posterior  part,  where 
it  forms  a  stiff  plate,  the  tarsus. 

The  skin  of  the  lids  differs  from  that  of  the  rest  of  the  body  merely 
in  its  thinness,  its  loose  attachment,  and  the  absence  of  fat  in  its 
corium  ;  the  papillae,  too,  are  less  marked  than  in  other  parts.  It  is 
covered  \vith  fine  downy  hairs,  which  are  provided  with  small  seba- 
ceous glands,  and  there  are  also  small  sweat-glands.  The  stratum 
Malpighii  of  the  epidermis  often  contains  pigment,  especially  in  the 
neighbourhood  of  the  inner  canthus.  Ramified  pigment-cells  are  found 
scattered  throughout  the  cutis  vera,  especially  in  the  superficial  layers 
around  the  vessels  and  hair- follicles  (Waldeyer).  Mast-cells  and 
plasma-cells  are  also  present  normally.  At  the  anterior  border  of  the 
lid  the  hairs  are  specially  differentiated  to  form  a  protection  to  the 
eyeball.  The  cilia  are  strong,  short,  curved  hairs,  arranged  in  two  or 
more  closely  set  rows.  The  hair-follicles  are  long  (1-5 — 2*5  mm.),  and 
pass  obliquely  from  the  anterior  border  towards  the  tarsus  ;  they  are 
surrounded  by  a  dense  fibrous  tissue,  which  in  the  upper  lid  is  con- 
tinuous with  the  tarsus  (Merkel).  The  cilia  are  more  scattered  towards 
the  inner  canthus. 

The  sebaceous  follicles,  like  the  cilia  themselves,  are  specially 
differentiated,  and  are  called  Zeiss's  glands.  They  are  larger  than 
usual,  so  as  to  supply  the  larger  hairs  which  they  lubricate.  They  are 
acinous  glands  of  the  usual  sebaceous  type. 

i 


2  THE    PATHOLOGY   OF   THE    EYE 

The  sweat-glands  in  this  neighbourhood  are  also  unusually  large, 
and  are  known  as  Moll's  or  modified  sweat-glands.  They  are  situated 
immediately  behind  the  hair-follicles,  and  their  ducts  open  into  the 
ducts  of  Zeiss's  glands  or  into  the  hair-follicles  themselves.  The 
glands  are  tubular,  lined  by  a  single  layer  of  cylindrical  cells,  the 
nuclei  of  which  are  near  the  basement  membrane.  The  ducts  are 
lined  by  a  double  layer  of  epithelial  cells,  the  inner  ones  being  cubical 
and  the  outer  flattened.  The  secreting  part  is  surrounded  by  a  layer 
of  unstriped  muscle-fibres  (Sattler),  which  are  much  better  marked 
than  those  said  to  be  present  about  ordinary  sweat-glands  (Tartuferi). 

The  margin  or  free  edge  of  the  lid  is  the  part  between  the  anterior 


FIG.  i. — THE  UPPER  LID.      x  5. 

K.  Position  of  Krause's  glands,  w.  Position  of  Waldeyer's  glands.  H.  Henle's 
glands.  M.  Meibomian  glands,  z.  Position  of  Zeiss's  and  Moll's  glands,  s.s.  Sulcus 
subtarsalis. 

and  posterior  borders,  and  has  therefore  been  called  margo  inter- 
marginalis.  It  is  covered  with  conjunctiva,  the  transition  taking  place 
at  the  anterior  border  (see  "  Conjunctiva").  This  border,  from  which 
the  cilia  spring,  is  rounded,  whilst  the  posterior  border,  which  lies  in 
contact  with  the  globe,  is  sharp.  The  capillarity  induced  by  this  sharp 
angle  of  contact  is  of  importance  in  the  proper  moistening  of  the 
surface  of  the  eye.  Immediately  anterior  to  the  posterior  border  is  a 
single  row  of  minute  orifices,  which  are  just  visible  to  the  naked  eye. 
These  are  the  orifices  of  the  ducts  of  the  Meibomian  glands.  Between 
this  row  of  puncta  and  the  anterior  border  is  a  fine  grey  line,  which  is 
of  importance  in  operations  in  which  the  lid  is  split,  as  it  indicates  the 
position  of  the  loose  fibrous  tissue  between  the  orbicularis  palpebrarum 
and  the  tarsus. 

The  tarsus  consists  of  extremely  dense  fibrous  tissue  ;  it  contains  no 
cartilage  cells,  so  that  the  term  "  tarsal  cartilage"  is  only  justified  in 


THE    LIDS  3 

so  far  as  it  defines  the  consistence  of  the  plate.  The  fibrous  tissue 
thins  off  imperceptibly  towards  the  attached  part  of  the  lid  into  the 
palpebral  fascia. 

Embedded  in  the  tarsus  are  some  enormously  developed  sebaceous 
glands,  the  Mcibomian  glands.  They  consist  of  nearly  straight  tubes, 
directed  vertically  and  opening  by  a  single  duct  on  to  the  margin  of 
the  lid.  The  tubes  are  closed  at  the  upper  end,  and  have  numerous 
small  caeca!  appendages  projecting  from  the  sides,  filled  with  glandular 
epithelium.  The  peripheral  cells  are  cubical,  staining  with  proto- 
plasmic stains  and  containing  no  fat ;  the  central  cells  are  filled  with 
fat  globules.  In  young  subjects  the  fat-free  cells  are  more  numerous, 
and  form  young  terminal  acini.  The  ducts  are  lined  with  cubical  cells, 
but  the  epithelium  becomes  stratified  at  the  orifices.  The  acini  are 
surrounded  by  a  lymph  space  lined  with  endothelium.  The  upper  end 
of  the  gland  is  occasionally  bent,  and  the  tube  may  even  form  nearly  a 
semicircle.  The  glands  number  from  20  to  30,  being  rather  fewer  in 
the  lower  than  the  upper  lid. 

Small  groups  of  serous  glands  are  not  infrequently  found  near  the 
convex  border  of  the  tarsus — Waldeyer's  glands  (Fuchs),  or  posterior 
tarsal  glands  (Waldeyer).1  They  resemble  minute  salivary  glands,  and 
are  therefore  similar  in  structure  to  Krause's  gla.nds(see  "Conjunctiva"). 

The  orbicularis  palpebrarum  consists  of  large  bundles  of  striped 
muscle,  which  are  cut  transversely  in  a  sagittal  section  of  the  lid ;  they 
are  attached  to  the  skin  by  loose  subcutaneous  tissue,  but  glide  freely 
over  the  tarsal  plates.  The  follicles  of  the  cilia  encroach  upon  the 
orbicularis,  and  separate  off  an  inferior  portion,  which  is  -known  as  the 
subtarsal  muscle  or  ciliary  muscle  of  Riolan.  This  consists  of  smaller 
bundles  lying  mostly  in  front  of,  but  partly  behind,  the  ducts  of  the 
Meibomian  glands.  Moll's  glands  separate  it  from  the  hair-follicles. 

The  insertion  of  the  levator  palpebrce  superioris  enters  into  the  upper 
part  of  the  upper  lid.  The  main  central  band  passes  into  the  upper 
border  of  the  tarsus.  The  anterior  insertion  is  a  flat  tendinous  expan- 
sion, the  bundles  of  which  pass  between  the  bundles  of  the  orbicularis 
to  be  attached  to  the  skin  of  the  middle  of  the  eyelid.  The  posterior 
insertion  into  the  fornix  conjunctive  does  not  enter  into  the  lid  proper. 

The  inferior  rectus  and  oblique  muscles  send  fibrous  strands  for- 
wards into  the  lower  lid  to  be  attached  to  the  tarsus  and  palpebral 
ligament. 

Besides  these  striped  muscles  there  is  a  layer  of  unstriped  muscle 
in  each  lid.  These  constitute  the  superior  and  inferior  tarsal  muscles  of 
M tiller.  The  fibres  of  the  upper  one  arise  from  amongst  the  striped 
fibres  of  the  levator,  pass  down  behind  it,  and  are  inserted  into  the 

1  There  is  much  confusion  in  terminology  here.  Waldeyer  calls  them  posterior  tarsal 
glands,  or  acino-tubular  glands  of  Krause,  and  says  they  were  first  represented  by  Klein  in 
Strieker's  '  Manual,'  and  described  in  detail  by  Wolfring  and  Ciaccio.  The  latter  called 
them  tarso-conjunctival  acinous  glands,  and  distinguished  them  from  Krause's  glands,  which 
he  called  subconjunctival  glands,  a  term  introduced  by  Sappey.  By  Italians  they  are  often 
called  Ciaccio's  glands.  They  are  distinct  in  situation  from  the  glands  now  commonly 
known  as  Krause's  glands,  and  are  much  less  constant.  At  the  same  time  they  may  be 
merely  outlying  acini  of  Krause's  glands,  which  are  notoriously  inconstant  in  situation. 
They  are  often  inaccurately  described  as  "  mucous  "  glands. 


4  THE    PATHOLOGY    OF   THE   EYE 

upper  border  of  the  tarsus.  The  inferior  lies  below  the  inferior  rectus, 
and  is  inserted  into  the  lower  tarsus. 

The  arteries  of  the  upper  lid  form  two  main  arterial  arches,  superior 
and  inferior,  the  former  lying  between  the  upper  border  of  the  tarsus 
and  the  orbicularis,  the  latter  in  a  similar  position  just  above  the  hair- 
follicles.  From  the  inferior  one  perforating  branches  pass  down  and 
then  back  between  the  Meibomian  glands.  In  the  lower  lid  there  is 
usually  only  one  arch  near  the  free  border,  but  there  is  sometimes  a 
second. 

There  are  two  venous  plexuses  in  each  lid  :  one,  post-tarsal,  passing 
to  the  ophthalmic  vein  ;  the  other,  pre-tarsal,  opening  into  subcutaneous 
veins. 

The  main  nerves  run  between  the  tarsus  and  the  orbicularis.  A  fine 
plexus  is  formed  between  the  tarsus,  orbicularis,  and  Riolan's  muscle, 
constituting  the  marginal  plexus  of  Mises.  The  minute  distribution  of 
the  nerve-fibres  has  been  investigated  by  the  Golgi  method  by  Bach. 

The  lymphatics  are  abundant ;  most  of  them  pass  to  the  pre-auricular 
gland,  but  a  few  from  the  nasal  side  pass  along  the  facial  vein  to  the 
submaxillary  glands. 

*  WALDEYER. — In  de  Wecker  and  Landolt,  Traite  d'Ophtalmologie,  i,  Paris,  1886 
(Bibliography,  ii,  p.  83).  SATTLER.  —  Arch.  f.  mikr.  Anat,  xiii.  BACH. — A.  f.  A.,  xxxiii,  1896. 


INFLAMMATION 

The  skin  of  the  lids  is  subject  to  most  forms  of  dermatitis.  Only 
those  types  of  bacterial  and  parasitic  inflammation  which  are  specially 
important  to  ophthalmologists  will  be  considered  here.  Variola,  vari- 
cella, vaccinia,  malignant  pustule  (anthrax),  and  glanders  (Strze- 
minski)  may  be  mentioned  as  occurring  in  this  situation. 

STRZEMINSKI. — Rec.  d'O.,  1900. 

BLEPHARITIS 

Blepharitis  occurs  in  two  forms — B.  squamosa  and  B.  ulcerosa.  In 
the  former  there  are  small  white  scales  at  the  edges  of  the  lids,  and  the 
skin  beneath  is  merely  hyperaemic.  The  condition  may  be  regarded 
as  a  seborrhcea  (Fuchs).  In  B.  ulcerosa  there  are  yellow  crusts  around 
the  hairs,  and  the  skin  is  ulcerated.  This  condition  is  a  true  eczema. 
Microscopically  the  hair-follicles  are  surrounded  by  round-celled  infil- 
tration, with  a  few  polymorphonuclear  leucocytes.  Where  the  skin  is 
normal  under  crusts  there  is  no  blepharitis,  but  the  crusts  are  due  to 
dried  conjunctival  secretion. 

Blepharitis  ulcerosa  often  leads  to  destruction  of  the  cilia,  so  that 
they  become  few,  scattered,  and  abortive  (madarosis) ,  or  to  an  altera- 
tion of  their  direction,  owing  to  the  contraction  of  cicatricial  tissue 
(trichiasis) ,  or  to  hypertrophy  of  the  border  of  the  lid,  which  droops 
owing  to  the  weight  (tylosis).  Eversion  of  the  border  of  the  lid,  with 
the  punctum,  may  follow,  due  to  cicatrisation  pulling  the  conjunctiva 
forwards.  The  lids  are  now  no  longer  apposed  to  the  globe,  or  to  each 


THE    LIDS 


5 


other  when  shut ;  the  tears  run  over  (epiphora),  the  skin  becomes  ecze- 
matotis  and  contracts,  and  so  the  eversion  is  increased,  until  ectropion 
is  fully  developed. 

According  to  Raehlmann  (2)  new  hair-follicles  are  actually  developed 
in  the  intermarginal  border,  especially  after  trachoma,  by  down-growths 
of  the  surface  epithelium. 

Trichiasis  must  not  be  confused  with  distichiasis,  which  is  a  con- 
genital condition.  I  have  seen  a  case  in  which  there  were  two  perfect 
sets  of  cilia  in  each  of  the  four  lids.  The  inner  rows  irritated  the 
cornea.  Kuhnt  has  examined  such  a  case  microscopically.  The  inner 
row  replaced  the  Meibomian  glands,  which  were  wholly  absent.  Moll's 
glands  were  hypertrophied,  and  there  was  a  second  row  of  Krause's 
glands  in  the  middle  of  the  tarsus. 

Blepharitis  is  occasionally  caused  by  animal  parasites.  Blepharitis 
acarica  (Raehlmann  [i])  is  caused  by  Demodex  folliculorum  in  the  hair- 
follicles.  In  phthiriasis  palpebrarum  (or  acarus)  the  pediculus  (or 
phthirius)  pubis,  or  crab-louse,  occurs  upon  the  eyelashes,  which  look 
very  dark  owing  to  the  black  nits  which  are  attached  to  them  (Chisolm). 
Only  two  cases  are  on  record  of  pediculus  capitis  being  found  here,  in 
spite  of  its  frequency  in  the  hair  (Kraemer). 

Treacher  Collins  has  recorded  an  extremely  rare  case  of  monilethrix 
affecting  the  eyelashes  and  eyebrows.  The  hairs  and  cilia  have  a 
beaded  appearance,  the  narrow  parts  being  unpigmented.  The  disease 
runs  in  families,  and  is  apparently  due  to  periodic  increased  activity  in 
the  rete  mucosum. 

Canities  or  whitening  of  the  eyelashes  has  been  described  by  Nettle- 
ship,  Tay,  and  others  in  sympathetic  ophthalmia.  It  may  also  occur 
in  leucoderma  (Treacher  Collins). 

Shedding  of  the  eyelashes  is  common  in  alopecia,  leprosy,  and  other 
conditions. 

RAEHLMANN  (i). — K.  M.  f.  A.,  xxxvii,  1899.  CHISOLM. — Am.  Jl.  of  Ophth.,  ix,  1892. 
KRAEMER. — Die  tierischen  Schmarotzer  des  Auges,  in  G.-S.,  x,  1899.  RAEHLMANN  (2). — 
A.  f.  O.,  xxxvii,  2,  1891.  KUHNT. — Z.  f.  A.,  ii,  1899.  TREACHER  COLLINS. — T.  O.  S., 
xix,  1899.  NETTLKSHIP.— T.  O.  S.,  iv,  1884.  TAY.— T.  O.  S..  xii,  1892. 

SYPHILIS 

Both  early  and  late  manifestations  of  syphilis  occur  in  the  lids,  but 
can  rarely  be  diagnosed  microscopically  from  other  inflammations. 
There  is  the  same  infiltration  of  the  tissues  with  lymphocytes,  the 
same  dilatation  of  blood-vessels  and  lymphatics.  Endothelial  pro- 
liferation, with  the  formation  of  groups  of  epithelioid  cells,  is  more 
marked,  but  is  not  pathognomonic.  There  is  also  more  extensive  pro- 
liferation of  the  fixed  connective-tissue  cells,  with  a  greater  development 
of  fibrous  tissue,  which  is  often  hyaline.  Giant-cells  often  occur,  but 
are  more  often  absent. 

Gummata  often  degenerate  in  the  centre,  and,  if  superficial,  break 
down  upon  the  surface  and  form  characteristic  ulcers.  They  often 
heal  with  the  formation  of  a  white  scar,  surrounded  by  a  pigmented 
zone.  Subcutaneous  scars  show  extreme  fibrous  tissue  formation,  with 


6  THE    PATHOLOGY    OF   THE   EYE 

very  few  nucleated  cells.  Sclerosis  of  the  vessels  is  also  extreme,  with 
proliferation  of  the  endothelium,  often  to  the  extent  of  obliteration  of 
the  lumen  and  thickening  of  the  adventitia. 

Gummata  of  the  lids  are  said  to  be  commoner  in  women  than  in 
men,  and  in  the  upper  lid  than  in  the  lower  (Hutchinson,  Jr.).  The 
necrotic  process  may  be  extreme  (phagedaenic),  leading  to  partial 
destruction  of  the  lids,  as  in  a  case  reported  bv  Hartridge. 

Chancre  of  the  lids  has  not  been  examined  microscopically.  The 
cases  up  to  1886  have  been  collected  by  de  Beck.  Most  of  them  are 
really  conjunctival,  as  shown  by  the  following  table  : 

On  the  cutaneous  surfaces  of  the  lids          .  .       4 

Lower  lid  margin,  inner  surface,  and  cul-de-sac     .  .     35 

At  the  inner  angle  .  25 

Upper  lid  and  cul-de-sac       .  .  .  .  23 

Ocular  conjunctiva  .  .  .  .  .6 

The  tarsus  is  particularly  liable  to  syphilitic  inflammation  (tarsitis 
sypliilitica).  It  is  much  enlarged,  so  that  the  lid  cannot  be  everted,  and 
is  of  cartilaginous  hardness.  When  cut  into  it  does  not  bleed.  Both 
lids  of  the  same  eye  may  be  affected.  It  is  a  tertiary  affection,  which 
runs  a  prolonged  course  of  several  months.  Cases  have  been  examined 
histologically  by  Rogman,  Reiner,  and  Basso,  who  found  hyaline 
degeneration  of  the  fibrous  tissue  with  few  nucleated  cells.  Near  the 
surface  the  tissue  was  infiltrated  with  round-cells  and  partially  re- 
placed by  granulation  tissue,  with  new-formed  connective  tissue.  In 
one  case  there  were  calcareous  deposits  (Basso).  The  vessels,  espe- 
cially the  small  arteries,  showed  hyaline  degeneration,  atrophy  of  the 
media,  slight  thickening  of  the  adventitia,  and  enormous  proliferation 
of  the  intima,  amounting  often  to  endarteritis  obliterans.  The  veins 
suffered  least.  In  one  case,  of  seven  years'  duration,  the  conjunctival 
epithelium  resembled  epidermis ;  in  another,  of  eight  years'  duration, 
the  conjunctiva  bulbi  was  xerotic. 

HUTCHINSON,  JR. — R.  L.  O.  H.  Rep.,  xii,  2,  1888.  ALEXANDER. — Syphilis  und  Auge, 
Wiesbaden,  1889.  HARTRIDGE. — T.  O.  S.,  xviii,  1898.  DE  BECK. — Hard  Chancre  of  the 
Eyelids  and  Conjunctiva,  Cincinnati,  1886.  ROGMAN. — Ann.  d'Oc.,  cxx,  1898.  REINER. — 
B.  z.  A.,  xxiii,  1898.  BASSO. — Ann.  di  Ott,  xxix,  1900. 

LUPUS 

In  lupus  the  nodule  consists  of  a  delicate  fibrous  reticulum  with 
numerous  vessels,  the  larger  meshes  being  filled  with  round-cells,  the 
smaller  with  smaller  cells  and  many  free  nuclei.  Giant-cells  are  present 
in  varying  numbers.  As  the  cells  in  the  centre  increase  in  numbers  the 
vascular  supply  is  interfered  with,  and  fatty  degeneration  and  dis- 
integration ensue.  In  the  epidermis  the  cells  of  the  rete  Malpighii 
undergo  proliferation  and  fatty  degeneration  ;  there  is  down-growth 
of  the  interpapillary  processes  on  the  one  hand,  and  encroachment  of 
the  lupus  infiltration  on  the  other.  Similar  changes  occur  in  the 
epithelia  of  the  glands  and  hair-follicles. 

The  down-growths  of  epithelium  are  occasionally  very  pronounced, 
and  have  led  to  the  diagnosis  of  a  combination  of  lupus  and  epithelioma 


THE    LIDS  7 

(lupus-carcinoma).  Such  a  case,  in  which  the  presence  of  tubercle 
bacilli  was  proved  by  inoculation,  has  been  described  by  Capauner. 

These  downgrowths  of  epithelium  are  common  in  many  inflamma- 
tory conditions,  and  are  probably  only  accentuated  in  lupus  by  the 
peculiar  combination  of  proliferation  and  ulceration,  granulation  and 
cicatrisation,  which  here  go  on  in  such  close  proximity.  There  is  no  suffi- 
cient reason  for  regarding  them  as  malignant  in  a  carcinomatous  sense. 

Tubercle  bacilli  are  usually  present  in  small  numbers,  and  can  be 
demonstrated  only  with  difficulty  in  sections.  Inoculation  experiments 
are  more  trustworthy. 

In  the  later  stages,  and  after  treatment,  the  nodules  may  be 
absorbed,  and  the  ulcers  may  completely  cicatrise. 

CAPAUNER. — Z.  f.  A.,  v,  1901. 

LEPROSY 

Leprosy  occurs  in  two  forms — the  maculo-ancesthetic  and  the  nodular. 
Both  occur  in  the  lids,  but  the  latter  is  much  more  frequent. 

The  disease  is  caused  by  the  bacillus  leprae  (Hansen,  1873),  which 
closely  resembles  the  tubercle  bacillus  in  staining  reactions,  appearance, 
and  dimensions,  though  it  is  somewhat  shorter  and  takes  the  stain 
more  readily.  Both  are  acid-fast,  and  are  therefore  stained  by  the 
Ziehl-Neelsen,  Gabbet,  and  other  methods.  This  is  probably  due,  as 
shown  by  Bulloch  and  Macleod  for  tubercle,  to  a  waxy  constituent. 
In  preparing  films  it  is  important  not  to  get  blood  mixed  with  the 
exuding  fluid,  so  that  the  nodule  should  be  well  clamped  at  the  base 
with  curved  forceps  before  incision.  The  bacilli  are  variable — straight, 
curved,  tapering  or  thickened  at  one  or  both  ends  ;  or  they  may  look  like 
a  row  of  spores — possibly  an  involution  form.  Unlike  human  tuber- 
culosis, the  bacilli  are  found  in  large  quantities,  chiefly  in  groups,  or 
bundles  like  bundles  of  cigars  (Franke  and  Delbanco).  They  have  not 
yet  been  successfully  cultivated  or  inoculated,  even  in  man  (Danielssen). 
It  is  much  disputed  whether  the  bacilli  are  intra-  or  extra-cellular ;  they 
appear  to  be  in  peculiar  large  cells,  lepra-cells  (Virchow),  or  "globi  " — 
possibly  leucocytes  enlarged  by  the  bacilli,  or  glreal  masses  (Unna), 
which  may  be  a  resting  stage  of  the  parasite  (Fernet).  The  bacilli  are 
very  widely  distributed  in  leprous  patients,  and  may  be  found  in  parts 
which  show  no  granulomatous  changes. 

Most  cases  of  nodular  leprosy  commence  with  infiltration  of  the 
eyebrows.  The  lids  are  affected  relatively  late  (Lie),  and  then  usually 
at  the  free  edge  or  margo  intermarginalis.  Here  there  may  be  a 
diffuse  infiltration,  or  a  row  of  several  small  nodules,  or  isolated 
nodules,  which  are  rarely  polypoid. 

Microscopically  there  is  usually  a  blood  or  lymph  vessel  in  the 
centre  of  the  nodule,  so  that  the  bacilli  are  carried  both  by  the  blood 
and  lymph  streams.  They  are  found  in  the  intima,  less  frequently  in 
intra-vascular  leucocytes.  The  capillaries  and  small  vessels  are  dilated, 
but  there  is  no  reaction  in  the  surrounding  tissues  until  the  bacilli  have 
escaped.  There  is  then  infiltration  of  the  tissues  with  round-cells  and 
moderate  proliferation  of  the  fixed  cells,  but  even  this  may  be  absent 


8  THE    PATHOLOGY   OF   THE    EYE 

in  the  presence  of  extra-vascular  bacilli.  The  reaction  is  much  less 
than  in  tuberculosis,  bacilli  occurring  in  cells  which  look  quite  normal 
and  may  be  showing  active  karyokinesis.  The  lymphoid  cells  become 
epithelioid,  lepra-cells  being  usually  in  the  oldest  parts  of  the  nodules, 
not  far  from  the  vessels  (Lie).  The  latter  become  sclerosed,  showing 
proliferation  of  the  intima  and  adventitia,  with  little  change  in  the 
media.  The  muscle-cells  here  often  have  pigment  granules,  which 
stain  exactly  like  the  bacilli.  The  nodules  are  always  vascular,  and 
show  new  formation  of  vessels. 

Where  there  is  no  vessel  in  the  centre  of  the  nodule,  the  infiltration 
is  often  around  small  nerve  twigs.  The  nerve  is  less  attacked  by  the 
bacilli  than  the  other  tissues,  so  that  one  sees  a  clearer  centre 
surrounded  by  a  ring  of  connective  tissue  densely  packed  with  them. 
They  occur,  however,  in  the  perineurium,  endoneurium,  and  in 
Schwann's  sheath,  forming  long  spindle-shaped  aggregations  in  the 
latter.  The  nerves  themselves  often  look  normal,  which  accounts  for 
the  retained  sensibility  in  the  early  stages.  The  growth  of  the  nodule 
is  always  slow,  but  generally  continuous. 

The  epidermis  remains  intact  for  a  long  time,  and  the  subcutaneous 
layers  are  free  from  bacilli.  Later,  the  infiltration  reaches  the  rete 
mucosum  and  nutrition  is  interfered  with,  the  deep  cells  become  horny 
earlier  than  normal,  and  ulceration  follows,  with  invasion  of  other 
organisms.  Less  often  the  bacilli  make  their  way  between  the  epithe- 
lial cells,  which  respond  by  increased  mitosis.  These  changes  also 
affect  the  hair-follicles  and  sebaceous  glands,  so  that  the  hairs  and  eye- 
lashes fall  out. 

There  is  a  marked  deposition  of  pigment  granules  in  the  rete 
mucosum,  especially  the  basal  layer,  also  to  a  less  extent  in  the  con- 
nective-tissue cells,  but  not  so  much  here  as  in  the  muscle-fibres  of  the 
arrectores  pilorum.  The  cells  of  the  sweat-glands  are  also  markedly 
pigmented,  though  rarely  invaded  by  the  bacilli,  contrasting  in  this 
respect  with  the  sebaceous  glands  and  hair-follicles. 

The  "  globi  "  consist  of  masses  of  bacilli,  and  may  be  so  large  as 
to  appear  as  fine  points  to  the  unaided  eye  in  stained  preparations,  a 
fact  which  seems  incompatible  with  their  being  contained  in  cells  (Lie). 

DANIELSSEN  AND  BOECK. — Traite  de  la  Spedalskhed,  Paris,  1848.  BULL  AND  HAXSEN. 
— The  Leprous  Diseases  of  the  Eye,  London,  1873.  UNNA. — Histopathology,  London,  1896. 
*  BORTHEN  AND  LIE. — Die  Lepra  des  Auges,  Leipzig,  1899.  FRANKE  AND  DELBANCO. — 
A.  f.  O.,  1,  2,  1900.  BABES. — Die  Lepra,  ii,  1901. 

RINGWORM,  FAVUS 

Ringworm  of  the  eyelids  and  eyelashes  has  been  frequently 
observed  ;  it  calls  for  no  special  mention  here. 

Only  a  few  cases  of  favus  of  the  lid  are  on  record,  but  its  occurrence 
is  probably  more  frequent  than  the  paucity  of  reported  cases  would 
lead  one  to  expect.  The  disease  commences  with  the  formation  of 
yellowish-red  vesicles,  and  rapidly  goes  on  to  the  formation  of  a  bright 
yellow  crust,  which  is  very  characteristic.  I  have  examined  one  case, 
and  there  was  no  difficulty  in  demonstrating  the  Achorion  Schonleinii. 
The  patient's  cat  was  also  examined,  but  without  result,  though  the 


THE    LIDS  9 

source  of  the  disease  in  cats  or  mice  has  been  almost  certain  in  some 
cases  (MacHardy,  Quincke,  Pick). 

NARKIEWICZ-JODKO. K.    M.    f.    A.,    viii,    1870.       SCHIESS-GEMUSEUS. — K.    M.    f.    A.,  xi, 

1873.  MACHARDY.— T.  O.  S.,  v,  1885.  QUIXCKE.— Monatsheft  f.  Derm.,  vi,  1887.  PICK. 
— A.  f.  Derm.,  1891.  LIBMAN.  — A.  of  O.,  xxvii,  1898.  GLOOR.—  A.  f.  A.,  xxxvii,  1898. 
TREACHER  COLLINS. — T.  O.  S.,  xxiii,  1903. 

XANTHELASMA — XANTHOMA 

Xanthoma  palpebrarum  occurs  almost  always  in  plates  (X.planum), 
but  occasionally  in  nodules  (A",  tuberosuni).  It  usually  commences  on 
the  inner  canthus  of  the  left  upper  eyelid,  and  may  form  a  semicircle 
round  the  eye  by  the  coalescence  of  patches.  Sooner  or  later  similar 
patches  occur  on  the  right  side,  the  disease  always  becoming  sym- 
metrical. The  plates  are  embedded  in  the  cerium,  very  slightly  or  not 
at  all  raised  above  the  surface,  yellow,  soft  and  smooth  to  the  touch. 
With  a  lens  the  patches  can  often  be  seen  to  consist  of  small  yellow 
granules,  with  a  central  pinkish  punctum. 

It  occurs  at  ages  from  twenty  to  eighty-four  (Hutchinson),  usually 
over  forty ;  is  more  common  in  females  than  in  males ;  occurs  in 
families,  and  may  be  hereditary.  Half  of  Hutchinson's  cases  suffered 
from  migraine  ;  one  sixth  had  had  jaundice,  but  this  is  commoner  in 
X.  multiplex  (Radcliffe-Crocker). 

Microscopically  the  changes  are  chiefly  in  the  middle  and  lower 
layers  of  the  corium,  and  consist  in  aggregations  of  large  epithelioid, 
multinucleated,  oval,  round,  or  polygonal,  finely  granular  cells,  lying  in 
a  fine  rneshwork  of  connective  tissue,  and  separated  from  one  another 
by  bands  of  connective  tissue.  The  cells  form  irregular  masses,  or 
whorls  and  nests,  this  arrangement  being  due  to  their  formation  round 
a  blood-vessel.  Yellowish-brown  pigment  is  scattered  about  within  and 
amongst  the  cells,  and  also  in  the  cells  of  the  rete  Malpighii,  a  large 
number  of  which  are  vacuolated.  The  xanthoma  cells  undergo  fatty 
degeneration  and  seem  to  run  together,  so  that  their  contour  is 
indistinct.  They  may  at  first  be  spindle-shaped,  but  later  are  pressed 
together  like  epithelial  cells. 

The  origin  of  the  cells  is  doubtful.  The  majority  of  authors  think 
they  are  connective-tissue  cells,  the  changes  occurring  most  where 
these  are  most  numerous,  viz.  near  the  vessels,  nerves,  glands,  and  hair- 
follicles,  and  this  leads  to  the  granular  arrangement.  They  have  also 
been  derived  from  endothelial  cells  (endothelioma  lipomatodes).  They 
were  early  derived  from  sebaceous  glands,  but  this  is  inaccurate 
(Waldeyer).  Unna  considers  that  the  fat  is  not  in  the  cells,  but  in 
lymph  spaces,  and  that  the  nuclei  are  free  in  it.  Pollitzer  traced  the 
cells  to  degenerated  muscle-fibres. 

The  fat  is  rather  an  infiltration  than  a  degeneration,  the  nuclei 
staining  well.  In  sections  obtained  by  freezing,  and  kept  in  glycerine, 
it  crystallises  in  long  needles. 

Dessauer  says  that  the  same  clinical  picture  can  result  merely  from 
hypertrophy  and  increase  of  sweat-glands  with  cystic  degeneration,  but 
this  requires  confirmation. 


IO 


THE    PATHOLOGY   OF   THE   EYE 


RADCLIKFE-CROCKER.— Diseases  of  the  Skin,  London,  1903.  HUTCHINSON. — Med.- 
Chir.  Trans.,  liv,  1871.  XANTHOMA  COMMITTEE. — Trans.  Path.  Soc.,  xxxiii,  1882. 
WALDEYER.  -  Virchow's  Arch.,  Hi,  1871.  PYE-SMITH. — Guy's  Hosp.  Rep.,  1877.  UNNA. — 
Histopathology  of  Diseases  of  the  Skin,  London,  1896.  POLLITZER.  —  New  York  Med. 
Jl.,  1899.  DESSAUEK. — A.  f.  O.,  xxxi,  3,  1885.  ALT.  — A.  of  O.,  viii,  1879;  Am.  Jl.  of 
Ophth.,  xiii,  1896. 

INFLAMMATION  OF  THE  GLANDS  OF  THE  LIDS 

Hordeolum,  or  Sty,  occurs  in  two  forms,  H .  externum  and  H.  internum. 

Hordeolum  externum  is  a  suppurative  inflammation  of  one  of 
Zeiss's  glands.  It  is  usually  caused  by  staphylococci. 

Hordeolum  internum  or  Meibomianum  is  a  suppurative  inflam- 
mation of  one  of  the  Meibomian  glands.  Owing  to  the  firm  tissue  in 
which  the  gland  is  embedded,  the  inflammation  is  more  severe  and 
more  prolonged.  The  abscess  opens  through  the  gland  duct  or  on  to 
the  conjunctival  surface.  The  inflammation  is  due  to  staphylococci, 
and  may  spread  to  the  surrounding  tarsus  and  lead  to  considerable 
necrosis  (tarsitis  necroticans)  (Mitvalski).  Maklakoff  reports  a  case  of 
chronic  purulent  inflammation  of  the  Meibomian  glands,  in  which 
Bacilhis  inucosus  ozcena  was  found.  It  was  also  found  in  the  nose. 
The  pus  exuded  from  the  duct-openings,  and  the  condition  had  existed 
for  five  years. 

CUENOD. — Bacteriologie  et  Parasitologie  clinique  des  Paupieres,  1894.  FUCHS. — 
K.  M.  f.  A.,  xvi,  1878.  MITVALSKI. — C.  f.  A.,  xxi,  1897.  MAKLAKOFF,  JR. — A.  f.  A.,  xliii, 
i,  1901. 

Chalazion  is  a  chronic  inflammatory  affection  or  granuloma  of  a 
Meibomian  gland.  The  older  observers  regarded  it  as  an  hordeolum 

which  had  not  gone  on  to  suppura- 
tion. Others  considered  it  a  simple 
retention  cyst.  These  do  occur, 
e.g.,  in  trachoma  (q.  v.),  but  are 
essentially  different  from  chalazia. 

In  a  chalazion  there  is  a  peculiar 
chronic  inflammation  which  pro- 
duces granulation  tissue  containing 
giant-cells  (Fuchs)  (Fig.  2).  de 
Vincentiis  called  it  a  granuloma 
giganto-cellulare.  The  epithelium  of 
the  acinus  first  proliferates  without 
forming  fatty  sebaceous  material,  so 
that  the  cytoplasm  stains  well.  The 
acinus  becomes  swollen  and  forms 
club-shaped  expansions.  The  cen- 
tral fatty  cells  are  imprisoned,  and 
break  down  into  granular  amor- 
phous flakes.  The  surrounding 
tissue  of  the  tarsus  is  densely  in- 
filtrated with  lymphocytes,  and  the  fixed  cells  proliferate.  This  process 
soon  becomes  the  predominant  one,  so  that  both  the  acini  of  the  gland 
and  the  periacinous  tissue  are  ultimately  lost  in  a  mass  of  granulation 


-  <:^:'^^ 


•:'~V-.Y. 

IP* 


'V  •. '£?'?* -'V 


FIG.  2.- — CHALAZION.      x  So. 
The  section  shows  granulation  tissue,  con- 
taining blood-vessels,  with  two  giant-cells  of 
the  Langhans  type. 


THE    LIDS  ii 

tissue.  This  contains  giant-cells,  which  are  said  to  be  derived  both 
from  the  glandular  epithelium  and  from  the  endothelium  of  the  peri- 
acinous  tissue.  According  to  Krause,  the  surrounding  infiltration  is 
the  primary  phase.  According  to  Fuchs,  the  glandular  changes  are 
primary,  and  he  compares  it  to  a  desquamative  catarrh  following 
prolonged  or  repeated  inflammation  of  the  conjunctiva  or  lid-margin. 
The  inflammatory  process  either  extends  up  the  ducts  of  the  glands, 
or  leads  to  obliteration  of  their  mouths. 

The  growing  tumour  presses  more  and  more  upon  the  surrounding 
tissue,  which  becomes  compressed,  and  forms  a  connective-tissue  cap- 
sule. This  is  least  developed  in  the  direction  of  least  resistance,  which 
is  usually  towards  the  conjunctival  surface,  and  here  the  granulation 
tissue  extends,  and  finally  breaks  through. 

The  chalazion  is  poor  in  vessels,  proliferation  taking  place  chiefly 
at  the  periphery.  The  centre  contains  remnants  of  glandular  tissue, 
infiltrated  with  cells,  lying  in  fibrous  tissue  which  has  few  cells.  The 
fibrous  development  probably  leads  to  retrogressive  changes  in  the 
blood-vessels,  and  the  central  parts  degenerate.  The  fibres  become 
hyaline  and  fuse  into  a  fluid  homogeneous  mass ;  the  cells  become 
vacuolated  and  finally  disappear.  The  tissue  does  not  give  the  re- 
actions of  mucin,  and  is  therefore  not  a  true  myxomatous  degeneration. 
The  giant-cells  also  degenerate,  so  that  they  are  more  numerous  in  the 
early  than  in  the  later  stages.  In  old  chalazia  the  entire  contents 
may  be  liquefied  and  may  form  a  cyst,  with  a  thick  fibrous  wall,  con- 
taining turbid  gelatinous  fluid. 

Bacteriology. — At  a  time  when  the  Langhans  type  of  giant-cell — 
with  the  nuclei  arranged  around  the  periphery  or  at  the  poles — was 
regarded  as  pathognomonic  of  tubercle,  chalazion  was  naturally  included 
in  this  category.  It  is  now  known  that  the  ordinary  irritation,  or 
foreign-body  giant-cell  (Fremdkorperriesenzell),  may  be  of  the  Langhans 
type.  Moreover  material  from  chalazia  inoculated  into  the  anterior 
chamber  of  rabbits  does  not  produce  tuberculosis  (Weiss,  Deutschmann, 
Landwehr,  etc.),  though  when  placed  in  the  peritoneal  cavity  of  guinea- 
pigs  it  may  cause  death  (Parisotti).  v.  Wichert  considered  twenty- 
eight  out  of  thirty-two  chalazia  tuberculous  on  anatomical  grounds, 
though  bacilli  were  only  found  twice,  and  inoculations  failed.  At  the 
same  time  it  seems  probable  that  in  exceptional  cases  chronic  tuber- 
culosis of  the  tarsus  may  show  the  clinical  picture  of  chalazion 
(v.  Michel,  Tangl,  and  v.  Wichert),  and  ordinary  chalazion  in  tuber- 
culous subjects  may  contain  tubercle  bacilli  (Tangl).  Inoculation  of 
dead  tubercle  bacilli  will  not  produce  the  complaint  (Deyl).  Palermo 
produced  tubercle  of  the  tarsus  by  inoculation  in  rabbits,  but  it  led  to 
ulceration  and  even  death,  but  no  evidence  of  chalazion.  He  regards 
the  condition  as  a  foreign-body  granuloma,  in  which  chemical,  physical, 
or  bacterial  irritation  may  play  a  part,  leading  to  a  desquamative 
catarrh,  with  adenitis  and  periadenitis. 

Specific  organisms  have  been  described.  Poncet  and  Boucheron, 
confirmed  by  Lagrange,  found  cocci  which  stained  by  Gram ;  they  were 
of  unequal  size,  and  were  possibly  nuclear  fragments  (Uhthoff  and 
Axenfeld). 


12  THE    PATHOLOGY   OF   THE   EYE 

Deyl  found  bacilli  invariably  in  fresh  chalazia  (chalazion  bacilli). 
He  admits  their  morphological  and  cultural  identity  with  xerosis 
bacilli.  Hala  found  them  in  large  numbers  in  young  chalazia  only. 
They  gradually  dwindle,  so  that  in  four  or  five  weeks  they  are  absent. 
They  are  short  thick  rods  with  rounded  ends,  one  usually  thicker  than 
the  other  ;  in  the  later  stages  they  are  larger,  and  show  more  segmenta- 
tion. In  common  with  Uhthoff  and  Axenfeld  and  others,  he  regards 
them  as  xerosis  bacilli. 

Priouzeau  found  staphylococci,  diplobacilli,  Friedlander's  pneumo- 
bacilli,  streptococci,  tetragenus,  leptothrix  ;  he  considers  staphylococci 
causal.  He  is  strongly  in  favour  of  the  infectious  nature  and  trans- 
missibility  of  the  disease,  both  on  insufficient  grounds. 

DE  VINCENTIIS.— Delia  Struttura  e  Genesi  del  Chalazion,  etc.,  Naples,  1875.  FUCHS. — 
A.  f.  O.,  xxiv,  2,  1878.  KRAUSE.  — Inaug.  Diss.,  Berlin,  1891.  WEISS.  —  K.  M.  f.  A.,  xxix, 
1891.  DEUTSCHMANN. — B.  z.  A.,  ii,  1891.  LANDWEHR. — Ziegler's  Beitrage,  xvi,  2,  1894. 
PARISOTTI. — Internal.  Congress  in  Rome  (see  C.  f.  A.,  xviii,  1894).  v.  WICHERT. — 
Nauwerck's  Path.  Anat.  Mittheil.,  xv,  1894.  DEYL. — Acad.  des  Sciences,  Prague,  1893-4. 
PALERMO. — Ann.  di  Ott.,  xxvi,  1896.  HALA. — Z.  f.  A.,  vi,  1901.  PRIOUZEAU. —  Ann.  d'Oc., 
cxix,  1898.  *  UHTHOFF  AND  AXENFELD. — In  Lubarsch  and  Ostertag,  1894,  1895-6,  1897-8-9. 
HENKE. — Deutsch.  path.  Gesellsch.,  iv,  1902. 


HYPERTROPHIC   AND   ATROPHIC    CONDITIONS 
HYPERTROPHIC  CONDITIONS 

Hypertrophic  conditions  of  the  lids  are  not  always  easy  to  dis- 
tinguish from  some  tumours,  e.  g.  lymphomata,  lipomata,  etc.  They 
are  often  associated  with  orbital  affections.  They  occur  typically  in 
elephantiasis  and  myxoedema. 

In  elephantiasis  lymphangioides  and  elephantiasis  Arabum  the 
condition  is  due  to  lymph  stasis.  Several  cases  have  been  collected  by 
Becker.  The  changes  are  chiefly  in  the  subcutaneous  tissue,  which  is 
enormously  hypertrophied  from  increase  of  fibrous  tissue,  mostly  in 
bands  or  networks,  other  parts  being  gelatinous,  with  soft  fine  fibres, 
and  many  nuclei  and  cells.  The  blood-vessels  and  lymphatics  are 
enormously  enlarged,  and  the  muscles  show  fibro-fatty  changes.  The 
epidermis  is  also  proliferated. 

BECKER. — A.  f.  O.,  xli,  3,  1895.     KO.NIGSHOFER. — Ophth.  Klinik,  1902. 

Allied  to  elephantiasis  are  the  cases  of  chronic  oedema  which  are 
occasionally  met  with.  Their  pathology  is  obscure,  and  the  tissues 
have  seldom  been  submitted  to  microscopic  examination.  In  a  case 
following  erysipelas,  Rombolotti  found  oedema  of  the  subepithelial 
tissues,  with  dilatation  of  the  lymph  spaces.  There  was  some  round- 
celled  infiltration,  and  marked  hyperplasia  of  the  fixed-tissue  elements. 
The  dilatation  of  the  lymph  spaces  was  less  marked  than  in  Polignani's 
case. 

POLIGNANI. — Lav.  della  Clin.  Oc.  di  Napoli,  iii.     ROMBOLOTTI. — A.  f.  A.,  xxxvi, 
ANDERSON  CRITCHETT. —  T.  O.  S.,  xix,  1899. 


THE    LIDS  13 

The  upper  lid  is  a  favourite  situation  for  elephantiasis  neuromatodes 
or  neuro=fibromatosis.  Cases  have  been  reported  by  Billroth,  Bruns, 
etc.  There  is  the  characteristic  hypertrophy  of  the  nerves,  and  also  a 
condition  of  lymph  stasis  and  fibromatosis  of  the  subcutaneous  tissues. 
The  condition  of  the  lid  in  the  case  reported  by  Rockliffe  and  myself 
was  as  follows  : 

The  upper  lid  was  enormously  swollen,  the  increase  in  tissue  being 
principally  upon  the  posterior  or  conjunctival  side,  resulting  in  marked 
ectropion  (Fig.  3).  This  increase  of  growth  consisted  of  masses  of 
convoluted  nerves  covered  by  inflamed  conjunctiva.  The  nerves  were 
generally  smaller  than  those  in  the  major  orbital  part  of  the  growth, 
but  showed  similar  hypertrophy  of  the  endo-  and  peri-neurium.  The 


FIG.  3. — PLEXIFORM  NEUROMA,      x  3. 

From  Parsons  and  Rockliffe,  Trans.  Path.  Soc.,  Liv.  Showing  ectropion, 
due  to  hypertrophy  of  nerves  in  the  posterior  part.  Note  the  subconjunctival  infil- 
tration and  the  dilatation  of  lymph  spaces  in  the  anterior  layers. 

nerve-fibres,  stained  by  Weigert's  method,  showed  comparatively  little 
change.  The  other  tissues  of  the  lid  exhibited  more  redema  and  con- 
gestion, great  dilatation  of  the  subdermal  lymphatics  being  a  marked 
feature. 

The  subject  of  plexiform  neuroma  will  be  discussed  more  in  detail 
in  treating  of  orbital  tumours. 

PARSONS  AND  ROCKLIFFE. — Tr.  Path.  Soc.,  Iv,  1904.  DE  SCHWEINITZ. — T.'Am.  O.  S., 
1891. 

The  lids  are  always  affected  in  myxoedema.  There  is  thickening 
and  degeneration  of  the  elastic  tissue,  and  in  less  degree  of  the  white 
fibrous  tissue.  There  is  usually  little  cellular  infiltration.  The  epithe- 
lium of  the  sebaceous  and  sweat-glands  becomes  swollen  in  the  early 


THE    PATHOLOGY   OF   THE    EYE 


stages,  and  degenerates  later.  The  root-sheaths  of  the  hairs  show 
irregular  protrusions,  probably  due  to  constriction  by  an  excess  of 
surrounding  fibrous  tissue.  Degeneration  of  the  hair-follicles  leads  to 
shedding  of  the  hairs  (Fig.  4).  The  arterioles  also  show  thickened 
fibrous  coats  (Fig.  5)  (Ord).  Halliburton  failed  to  find  any  appre- 
ciable increase  of  mucin  in  the  skin  in  myxcedema. 

ORD.  —  Med.-Chir.  Trans.,  Ixi,  1877. 
xxi,  Suppl.,  1888. 


"COMMITTEE  ON  MYXCEDEMA.  —  Trans.  Clin.  Soc., 


Hypertrophy  of  the  tarsus  alone,  and  even  ossification,  may  occur, 
as  in  a  case  reported  by  Herbert.      Calcification   in  the  conjunctiva 


FIG.  4. 


FIG.  5. 


FIG.  4. — MYXCEDEMA.      x  50. 

After  Orr,  Med.-Chir.  Trans.,  Ixi.  Showing  thickening  of  the  fibrous  walls 
of  the  hair-follicles,  and  irregular  bulging  of  the  root-sheath,  either  due  to  budding 
from  its  surface  or  constriction  by  surrounding  fibrous  tissue.  The  hairs  are  in 
process  of  being  shed. 

FIG.  5. — MYXCEDEMA.      x  50. 

After  Orr,  Med.-Chir.  Trans.,  Ixi.  Showing  Meibomian  glands  and  arterioles, 
with  thickened  fibrous  coat. 

tarsi  is  not  uncommon  in  natives  of  India,  according  to  this  observer. 
(Cf.  "Conjunctivitis  petrificans.") 

HERBERT. — T.  O.  S.,  xxi,  1901. 

ATROPHIC  CONDITIONS 

In  senile  atrophy  there  is  degeneration  of  both  elastic  and  white 
fibrous  tissue  (Unna).  The  former  is  broken  up  into  granules  and 
globules,  which  stain  with  elastic  tissue  stains  (Weigert's,  acid  orcei'n). 
Small  nodules  of  lymphocytes  are  common.  The  hair  papillae  are 
shrunken,  with  cornification  of  the  outer  root-sheaths ;  the  sebaceous 
glands  are  enlarged. 


THE   LIDS  15 

In  blepharochalasis  (Fuchs)  the  skin  of  the  upper  lid  becomes  so 
thin  that  it  lies  in  countless  little  wrinkles.  It  occurs  at  all  ages  in 
cases  in  which  there  have  been  frequent  antecedent  cedematous  swell- 
ings, c.  g.  after  recurrent  neurotic  oedema.  The  small  superficial 
veins  are  dilated.  Anatomically  there  is  atrophy  in  all  parts — the 
papillae  are  much  flattened  or  have  disappeared  ;  the  subcutaneous 
tissue  is  loose,  consisting  of  finer  fibres  with  wider  meshes  than 
normal ;  the  elastic  tissue  is  finer  and  more  discrete  (Fehr). 


FUCHS. — Wien.  klin.  Woch.,  1896.     FEHR. — C.  f.  A.,  xxii, 

Atrophy  of  the  tarsus  occurs  in  trachoma  (q.  v.). 

TUMOURS 

MOLLUSCUM    CONTAGIOSUM 

Molluscum  contagiosum  occurs  not  very  commonly  as  a  small,  firm, 
hemispherical,  umbilicated  tumour,  at  first  sessile  and  waxy-looking, 
later  opaque  yellow  and  pedunculated. 

In  vertical  section  the  tumour  consists  of  wedge-shaped  lobules, 


FIG.  6. — MOLLUSCUM  CONTAGIOSUM.      x  55. 

The  section  shows  a  typical  tumour,  with  the  epithelium  arranged  in  loculi. 
The  transition  of  the  cells  to  "molluscum  bodies,"  and  their  extrusion  into  the 
orifice,  are  seen. 

separated  by  thin   fibrous  septa,  and  enclosed,  except  on  the  surface, 
by  a  fibrous  capsule  (Fig.  6).      The   border   is  continuous  with    the 


16  THE    PATHOLOGY   OF   THE    EYE 

epidermis,  each  lobule  is  bounded  by  palisade  epithelium,  and  round 
nucleated  epithelial  cells  adjoin  this.  These  cells  show  various  stages 
of  molluscous  degeneration,  those  near  the  surface  being  most 
advanced.  This  consists  of  a  hyaline  degeneration,  with  enlargement 
of  the  cell,  until  it  finally  forms  a  homogeneous  mass  or  mollttscum 
body.  These. bodies,  which  do  not  stain  with  ordinary  dyes,  accumu- 
late at  the  mouth  of  the  lobule,  and  the  tumour  may  be  emptied  by 
squeezing  them  out. 

It  was  formerly  thought  that  the  growth  consisted  of  altered 
sebaceous  glands.  The  degeneration  is  now  generally  considered  to 
be  in  the  prickle-cells  of  the  upper  (Thin)  or  lower  (Radcliffe-Crocker) 
layers  of  the  rete.  Charles  J.  White  says  that  the  material  is  not 
hyaline  or  colloid  substance,  but  normal  keratin,  reacting  like  corneous 
epithelioma  to  polarised  light  (Piffard). 

A  unique  case  of  molluscum  contagiosum  of  the  bulbar  conjunctiva 
has  been  recorded  by  Ballaban. 

Salzer  records  the  case  of  a  lady  with  molluscum  contagiosum,  in 
which  it  seemed  probable  that  she  had  contracted  it  from  pigeons ; 
these  had  growths  on  the  beak,  said  to  be  epithelioma  contagiosum  of 
fowls.  Shattock  has  seen  molluscum  contagiosum  in  bunting. 

The  disease  is  probably  due  to  an  organism.  Psorosperms  were 
invoked,  but  found  few  supporters.  Robey  found  only  the  Staphylo- 
coccus  epidermidis  albus  of  Welch. 

RADCLIFFE-CROCKER. — Diseases  of  the  Skin,  London,  1903.  WHITE  AND  ROBEY. — 
Jl.  of  Med.  Research,  vii,  1902.  *MUETZE. — A.  f.  A.,  xxxiii,  1896.  BALLABAN. — A.  f.  A., 
xlvii,  1903.  SALZER. — Munch,  med.  Woch.,  1896;  Brit.  Jl.  Derm.,  ix,  1897.  SHATTOCK. — 
Tr.  Path.  Soc.,  xlix,  1898. 

VERRUCA 

Warts  occur  upon  the  lids  and  the  lid  margins,  especially  the  senile 
form  (V.  senilis  or  keratoma  senile).  They  are  usually  flat,  soft  or 
hard  according  to  the  amount  of  corneous  change,  often  multiple. 

Senile  warts  are  often  multiple.  They  show  little  papillary 
proliferation,  but  often  downgrowths  of  plugs  of  epithelium.  These  do 
not  necessarily  prove  malignancy,  but  it  is  certain  that  these  warts  are 
liable  to  degenerate  into  epithelioma  or  rodent  ulcer.  On  the  other 
hand,  they  not  infrequently  fall  off  spontaneously.  The  epithelium  is 
usually  thickened,  with  a  moderate  increase  in  the  horny  layers  ;  the 
cells  are  often  pigmented. 


CORNU    CUTANEUM 

Cutaneous  horns  grow  rarely  on  the  lids  or  their  edges.  They  are 
usually  solitary,  conical  with  rounded  apices. 

The  papillae  at  the  base  are  usually  hypertrophied,  and  extend 
upwards  a  short  distance  into  the  horn,  stopping  sooner  in  the  axis 
than  at  the  periphery  (Fig.  7).  The  essential  change,  however,  is  in 
the  prickle-cells,  which  proliferate  rapidly,  the  young  cells  quickly 


THE    LIDS 


becoming  horny  without  being  shed.  They  thus  accumulate  and  form  the 
main  mass  of  the  growth.  The  horny  cells  are  arranged  in  columns 
of  concentric  laminae,  with  similar  cells 
irregularly  placed  in  the  interstices, 
cementing  them  together.  The  hair- 
follicles  and  ducts  of  the  sweat-glands 
participate  in  the  epithelial  proliferation. 
That  the  condition  is  dependent  upon 
epithelial,  and  not  papillary  proliferation 
(Unna),  is  shown  by  the  growth  of  horns 
where  there  are  no  papillae,  e.  g.  on  a 
cicatrix  (Bland-Sutton),  on  the  cornea 
of  a  cow  (Baas),  on  a  staphylomatous 
pseudo-cornea  (Arnold  Lawson).  These 
cases,  however,  are  open  to  different 
interpretation  (see  "Cornea"). 

MITVALSKI. — Arch.f.  Derm. ,xxvii,  1894.  BLAND- 
SUTTON. — Tumours,  London,  1902.  BAAS. — C.  f. 
Path.  u.  path.  Anat.,  viii,  1897.  LAWSON. — T.  O.  S., 
xx,  1900. 

FIBROMA 

Fibromata  of  the  lids  are  usually  soft 
and  polypoid,  the  surface  being  smooth 
or  papillary.  The  fibrous  tissue  varies 
greatly,  being  often  gelatinous  in  the 
smallest  tumours,  coarse  and  compact  in 
the  larger  ones,  frequently  with  hyaline 
degeneration.  The  tumours  are  usually 
richly  supplied  with  blood-vessels,  which 
often  give  rise  to  haemorrhages,  resulting 
in  pigmentation  with  blood  pigment.  All 


FIG.  7. — CUTANEOUS  HORN,      x  16. 
The  "  horn  "  was  removed  from  the 
edge  of  the   lid.     The  papilloma-like 
*•    "    .  base  is  seen,  and  the  masses  of  adherent 

the  cells  may  become  pigmented,  besides  corneous  scales.    The  base  is  com- 

the    normal    chromatophores   in    the   sub-    posed  of  vascular  fibrous  tissue  covered 

epidermal  layers.     Mast-cells  are  present  b^  .ePider.mis.  the  jnner  boundary  of 

i  i  j    TT  M  which  is  faintly  visible. 

in  large  numbers,  and  Unna  describes  a 

special  type  as  the  most  striking  constituent ;  with  polychrome 
methylene  blue  they  show  a  dense  oval  halo,  staining  red,  and  about 
double  the  size  of  the  contained  mast-cell  with  its  small  blue  nucleus. 

Owing  to  their  shape  and  exposed  situation,  fibromata  are  liable  to 
injury,  resulting  in  the  haemorrhages  already  mentioned  and  inflam- 
matory reaction.  They  may  then  show  marked  vascular  congestion, 
with  increase  of  intra-vascular  leucocytes,  and  dense  infiltration  with 
round-cells. 

Rumschewitsch  has  described  a  myxoma  of  the  upper  lid,  which  was 
probably  only  an  cedematous  fibroma. 

Many  fibromata  are  in  reality  neuro-fibromata  (molluscum  fibrosum) 
forming  polypoid  tumours,  having  the  same  structure  as  diffuse  neuro- 
fibroma. 

RUMSCHEWITSCH. — K.  M.  f.  A.,  xxviii,  1890. 


i8  THE    PATHOLOGY   OF   THE   EYE 

LlPOMA 

The  skin  of  the  lid  is  peculiar  in  having  no  adipose  tissue ;  hence 
lipomata  of  the  lid  are  probably  always  secondary  extensions  from  the 
orbit.  These  are  generally  congenital  fibre-fatty  tumours  (see  "  Con- 
junctiva"), which  may  send  processes  under  the  skin,  usually  running 
between  the  muscles  and  the  tarsus. 

Vossius  published  a  case  which  he  regarded  as  a  true  lipoma  of  the 
upper  lid  ;  others  have  been  diagnosed,  but  with  scanty  and  insufficient 
details. 

Wingenroth  published  a  remarkable  case  of  symmetrical  tumours 
in  all  four  eyelids  of  a  woman  set.  50.  They  consisted  of  myxomatous 
tissue,  with  large  star-shaped  cells,  and  with  isolated  and  aggregated 
fat-cells.  There  were  multiple  lipomata  over  the  body.  The  author 
regarded  the  tumours  as  lipomata  with  myxomatous  degeneration, 
though  the  possibility  of  elephantiasis  or  of  multiple  neuro-fibromata 
received  consideration.  In  any  case  it  is  doubtful  if  the  tumours  were 
true  primary  growths  of  the  lids. 

Vossius. — B.  d.  o.  G.,  1895.     WINGENROTH. — A.  f.  O.,  li,  2,  1900. 

ANGIOMA 

Angiomata  arise  from  the  blood-vessels — haemangiomata, — and  from 
the  lymphatics — lymphangiomata. 

Haemangiomata  are  either  capillary  or  cavernous.  Capillary 
haemangiomata  are  either  congenital  (capillary  ntzvi)  or  acquired  (telan- 
gieclasis).  In  either  case  they  consist  of  capillaries,  increased  in  size 
and  number,  and  closely  aggregated.  Cavernous  ncevi  are  circumscribed 
and  composed  of  thin-walled  veins  and  sinuses,  bound  together  by  a 
small  amount  of  cellular  connective  tissue.  The  walls  often  consist 
simply  of  endothelium  lying  on  the  connective  tissue.  A  few  small 
arteries  open  into  the  sinuses  without  the  intervention  of  capillaries. 

Lymphangiomata  can  only  be  diagnosed  microscopically  from 
haemangiomata  when  the  spaces  contain  no  blood.  The  lymph  usually 
appears  in  sections  as  granular  coagulum  containing  a  few  lympho- 
cytes, or  as  a  homogeneous  hyaline  material.  Often,  however,  the 
diagnosis  is  impossible  in  the  absence  of  the  clinical  appearances,  as 
blood  enters  the  spaces  during  the  operation  for  removal  (see  "  Con- 
junctiva "). 

LYMPHOMA 

Lymphomata  are  small  round-celled  tumours,  which  often  cannot 
be  distinguished  histologically  from  small  round-celled  sarcomata. 
Many  of  them  belong  to  those  indeterminate  cases  which  also  offer  great 
difficulties  in  clinical  classification,  and  are  variously  described  as 
lymphorna,  lymphadenoma,  lympho-sarcoma,  etc.  They  occur  in  the 
lids  and  orbits,  being  often  symmetrical,  and  not  infrequently  involving 
all  four  lids.  Hochheim  divides  them  into  four  groups  : 

i.  Simple  lymphomata. — Most  cases  reported  are  orbital,  e.  g. 
Silcock's. 


THE    LIDS  19 

2.  Leukcemic  tumours  in  patients  suffering   from   leukaemia.      They 
were  found  in  all  four  lids,  under  the  skin,  in  a  case  of  Leber's;  between 
the  conjunctiva  and  tarsus  in  a  case  of  Birk's  ;  most  are  orbital. 

3.  Pseudo-leukamic  tumours,  usually  in  anaemic  patients,  the  type 
of    anaemia   varying   or   being    insufficiently    investigated.       Bronner 
reports  a  case  involving  all  four  lids,  and  other  lid  cases  are  quoted 
from  Guaita,  Axenfeld,  Dutoit,  etc.;  most  are  orbital. 

4.  Doubtful  cases. 

The  diagnosis  of  these  cases  depends  entirely  upon  clinical  details. 
Histologically  they  are  all  tumours  composed  of  masses  of  small  round- 
cells,  resembling  lymphocytes,  lying  in  a  fibrous  reticulum,  which  often 
forms  a  definite  stroma  between  the  individual  cells.  They  are  not 
usually  encapsuled,  but  the  neighbouring  muscles,  etc.,  are  infiltrated 
with  lymphocytes.  There  is  often  endothelial  proliferation,  and  some- 
times an  excess  of  eosinophile  corpuscles.  Their  vascularity  varies. 

Lymphoma  has  been  used  as  a  generic  term  for  follicular  conjunc- 
tivitis, trachoma,  etc.,  by  Reid,  an  example  which  should  not  be  copied, 
as  it  leads  to  the  confusion  of  very  different  conditions,  which  are 
gradually  being  differentiated. 

*BUTLIN  AND  OTHERS. — Discussion  on  Lymphadenoma,  Tr.  Path.  Soc.,  liii,  1902. 
SILCOCK. — T.  O.  S.,  viii,  1888.  LEBER. — A.  f.  O.,  xxiv,  i,  1878.  BIRK. — St.  Petersburger 
med.  Woch.,  1883.  BRONNER. — International  Congress,  Edinburgh,  1894.  MELLER. — 
A.  f.  O.,  1,  i,  1900.  *HOCHHEIM. — A.  f.  O.,  li,  2,  1900.  *DUTOIT. — A.  f.  A.,  xlviii,  1903. 


SARCOMA 

Reported  cases  of  primary  sarcoma  of  the  lids  are  rare,  but  probably 
afford  little  idea  of  its  relative  frequency.  Wilmer  (1894)  collected 
thirty-five  cases,  Veasey  (1899)  added  thirteen,  and  Friedenwald  (1900) 
six  more.  Wilmer  found  the  age  of  the  patients  to  vary  from  ten 
months  to  seventy-six  years ;  the  size  varied  from  that  of  a  pea  to  a 
large  apple.  In  12  per  cent,  all  four  lids  were  involved.  In  40  per 
cent,  recurrence  is  reported ;  but  the  numbers  are  too  few  to  admit  of 
accuracy  in  percentages. 

The  growth  may  arise  from  any  structure  in  the  lid  except  the 
epithelium.  Many  spread  from  the  conjunctiva  ;  some  originate  in 
pigmented  naevi  (Hohemberger),  but  these  would  now  be  classified 
differently  by  many  (see  "  Conjunctiva  ")•  It  is  probable  that  some  are 
in  reality  primarily  orbital. 

Histologically  all  types  of  sarcoma  are  represented  :  round-celled 
(43  per  cent.,  many  of  which  are  doubtful — v.  "  Lymphoma  ") ;  spindle- 
celled  (40  per  cent.,  more  probably  the  majority) ;  mixed-celled  (17 
percent.);  myxosarcoma  (n  per  cent.).  Multinuclear  cells  resembling 
giant-cells  may  occur,  as  in  many  sarcomata  other  than  true  myeloid. 
Angiosarcomata  and  alveolar  sarcomata  also  occur,  and  are  probably 
endotheliomata.  Probably  about  half  the  cases  are  pigmented. 

Wadsworth  and  Verhoeff  have  reported  a  case  of  leucosarcoma  of 
the  lower  lid  associated  with  a  melanotic  sarcoma  of  the  limbus  ;  the 
tumours  were  in  contact.  The  only  other  similar  case  seems  to  be 
that  of  Szulislawski. 


20  THE    PATHOLOGY    OF    THE  EYE 

VAN  DUYSE  AND  CRUYL. — Ann.  d'Oc.,  xcviii,  1887  ;  ci,  1889.  HOHEMBERGER. — A.  f.  O., 
xxxviii,  1892.  *WILMER. — T.  Am.  O.  S.,  1894.  SZULISLAWSKI. — C.  f.  A.,  xx,  1896. 
PAGE. — A.  d'O.,  xvii,  1898.  VEASEY.— T.  Am.  O.  S.,  1899.  CAPELLINI. — Ann.  di  Ott., 
xxviii,  1899.  FRIEDENWALD. — T.  Am.  O.  S.,  1900.  UE  BERARDINIS. — Ann.  di  Ott.,  xxix, 
1900.  WADSWORTH  AND  VERHOEFF. — T.  Am.  O.  S.,  1901.  WORK  DODD. — T.  O.  S., 
xxiii,  1903. 

ENDOTHELIOMA 

Endotheliomata  are  said  to  be  common  in  the  lid.  They  are 
tumours  which  start  in  the  endotheiium  of  the  blood  or  lymphatic 
vessels.  There  can  be  no  doubt  that  such  tumours  form  an  important 
class,  and,  when  typical,  are  not  difficult  to  differentiate  from  other 
sarcomata  or  from  epitheliomata.  On  the  other  hand,  endothelial 
proliferation  is  common  in  many  tumours  and  granulomata,  whilst  the 


FIG.  8. — MELANOTIC  SARCOMA  OF  LID.      x   13. 

From  a  girl  aet.  17.  Small  "  mole  "  noticed  six  or  seven  years.  The  growth 
infiltrates  the  whole  of  the  lid  border,  and  large  pigmented  cells  extend  up  along 
the  conjunctiva  and  Meibomian  ducts.  The  cells  vary  in  size  and  shape,  show  a 
tendency  to  alveolation  in  places,  and  probably  arose  from  a  congenital  nsevus. 

endotheiium  in  many  endotheliomata  is  said  to  so  alter  that  the  cells 
become  spindle-shaped,  asteroid,  etc.,  and  they  cannot  be  distinguished 
from  embryonic  connective-tissue  cells.  How  far  this  is  true  may  be 
held  open  to  doubt  in  the  present  state  of  knowledge.  I  consider  that 
the  term  endothelioma  is  useful  where  the  origin  from  endotheiium  can 
be  demonstrated  or  is  reasonably  probable;  but  where  great  metaplasia 
(v.  Hansemann),  or  change  in  the  form  of  the  cells,  is  supposed  to  have 
occurred,  resulting  in  atypical  forms,  I  think  the  term  is  better  avoided, 
the  growths  being  called  sarcomata,  according  to  the  old  nomenclature. 
Only  a  false  idea  of  certitude  is  arrived  at  by  dogmatic  nomenclature, 
and  the  effect  is  to  retard  precise  knowledge.  Hinsberg  considered 


THE    LIDS 


21 


four  out  of  eight  epitheliomata  of  the  lid  to  be  endotheliomata,  and 
Ginsberg  three  out  of  six  ;  these  are  probably  examples  of  enthusiasm 
outrunning  discretion.  The  subject  will  be  dealt  with  more  fully  in 
considering  sarcomata  of  the  choroid. 

v.  HANSEMANN. — -Die  mikr.  Diagnose  der  bosartigen  Geschwiilste,  Berlin,  1897. 
HINSBERG. — Beitrage  zur  klin.  Chirurgie,  xxiv,  1899.  GINSBERG. — Grundriss  der  path. 
Histologie  des  Auges,  Berlin,  1903. 


EPITHELIOMA 

Epithelioma  is  one  of  the  commonest  tumours  of  the  lids.  As 
elsewhere,  its  favourite  site  is  the  meeting  place  of  different  kinds  of 
epithelium,  so  that  it  commences  most  frequently  at  the  lid  margin, 
usually  of  the  lower  lid. 


FIG.  9. — EPITHELIOMA  OF  LID.      x    14. 

This  is  a  general  view  to  show  the  downgrowing  processes  of  epithelium. 
Some  can  be  seen  to  fade  off  imperceptibly  into  the  underlying  stroma,  which  is 
densely  infiltrated  with  round-cells.  "Cell-nests"  are  seen,  but  some  of  these  have 
dropped  out,  leaving  spaces. 

Microscopically  there  is  great  downgrowth  of  the  interpapillary 
processes  of  the  rete,  and  secondary  processes  bud  off  from  these 
laterally  as  well  as  terminally,  and  anastomose,  forming  a  coarse  epi- 
dermal network  (Fig.  9).  Buds  may  also  come  off  from  the  hair- 
follicles,  and  probably  from  the  sweat  and  sebaceous  glands,  but  this  is 
doubtful.  It  is  generally  held  that  the  epidermal  epithelium  invades 
the  corium  by  proliferation,  but  some  pathologists  consider  that  an 
"  infective  "  activity  transforms  the  connective-tissue  cells  into  epithelial 
cells.  It  is  certain  that  in  many  places,  particularly  at  the  ends  of  the 


22  THE    PATHOLOGY   OF   THE   EYE 

growing  plugs,  the  distinction  between  epithelial  and  connective-tissue 
cells  is  to  a  large  extent  lost,  and  it  is  impossible  to  say  of  some  cells 
in  this  area  to  which  category  they  belong.  Here  the  basement 
membrane  is  entirely  lost,  and  these  features  are  of  extreme  importance 
in  settling  the  question  of  malignancy  and  discriminating  between  epi- 
thelioma  and  benign  epithelial  proliferation  with  down-growth,  such  as 
occurs  in  many  warts  and  inflammatory  conditions — notably,  however, 
in  the  conjunctiva.  Another  point  of  importance  is  the  condition  of 
the  connective-tissue  stroma  between  the  plugs.  The  cancerous 
epithelium  exerts  an  irritating  influence  upon  the  tissues,  which  respond 
by  inflammatory  infiltration.  The  stroma  becomes  packed  with  lym- 
phocytes, which  separate  and  break  up  the  fibres  ;  the  tumour  may 
disintegrate  or  slough  from  obliteration  of  the  vessels,  induced  by  pres- 
sure of  the  epithelium  and  leucocytes,  aided  by  endarteritis.  This 
inflammatory  infiltration  is  usually  absent  in  benign  growths,  but  I 
have  seen  it  in  a  case  of  papilloma  which  had  been  treated  with  glacial 
acetic  acid. 

The  epithelial  plugs  retain  to  a  large  extent  the  structure  of  the 
epidermis,  having  cylindrical  cells  at  the  periphery  ;  prickle-cells,  often 
particularly  large  and  well-developed,  within  ;  and  in  the  centre  stratified 
horny  cells.  The  latter  are  often  compressed  into  cell-nests,  with 
laminae  like  the  layers  of  an  onion  ;  there  are  often  multinucleated 
cells  in  the  centre,  and  "  colloid  "  cells  are  sometimes  found.  Cell- 
nests  are  also  found  free  in  the  stroma.  They  are  not  pathognomonic 
of  epithelioma. 

The  stroma  and  its  vessels  never  invade  the  epithelial  plugs,  but 
polymorphonuclear  leucocytes  are  often  found  between  the  epithelial 
cells.  The  latter  sometimes  show  vacuolation,  the  nuclei  being  pressed 
to  one  side.  Degenerative  changes  are  most  marked  in  the  middle  of 
the  plugs,  and  the  cells  may  here  break  down  into  a  granular  or  striated 
coagulum,  which  stains  deeply  with  hasmatoxylin  and  probably  con- 
tains mucin.  In  this  manner  gland  tubes  may  be  simulated.  The 
surface  of  the  growth  commonly  degenerates,  forming  a  malignant 
ulcer. 

Hutchinson  has  described  a  crateriform  idcer  which  much  resembles 
rodent  ulcer  and  affects  the  same  regions,  but  is  microscopically  an 
epithelioma.  It  occurs  as  a  bossy  lump  with  a  conical  summit,  which 
later  ulcerates. 

Mayeda  has  recently  investigated  the  subject  of  malignant  epithelial 
growths  of  the  lid,  and  has  seen  reason  to  believe  that  epithelioma  is 
less  common  than  the  glandular  type  of  carcinoma  (v.  infra). 

PURTSCHER. — A.  f.  A.,  x,  1881.  HUTCHINSON. — Trans.  Path.  Soc.,  xl,  1889.  MAYEDA. 
— B.  z.  A.,  Ivi,  1903. 


RODENT  ULCER 

The  lids  and  sides  of  the  nose  are  favourite  situations  for  rodent 
ulcer. 

Most  Continental  writers  regard  this  growth  as  a  variety  of  epi- 


THE    LIDS  23 

thelioma,  a  view  supported  by  Hutchinson  and  others  in  England. 
Others  believe  it  starts  from  the  sebaceous  glands  (Thiersch,  Butlin), 
from  the  sweat-glands  (Thin,  Norman  Walker),  or  from  the  hair- 
follicles  (Bowlby  and  others).  It  is  generally  agreed  in  England  that 
it  is  a  subepidermal  growth  with  the  structure  of  a  glandular  cancer, 
and  quite  distinct  from  squamous-celled  epithelioma.  As  a  late  event 
the  rete  may  be  involved,  but  unless  this  happens  the  greater  part  of 
the  growth  is  made  up  of  granulation  tissue,  the  epithelial  proliferation 
being  comparatively  moderate  (Radcliffe-Crocker). 

The  cells  of  rodent  ulcer  are  smaller  than  ordinary  epithelial  cells, 
and  occur  in  irregular  masses  and  bands  beneath  the  epidermis 
or  ulcerated  surface  (Fig.  10).  The  outer  cells  are  usually  more  or  less 


FIG.  10. — RODENT  ULCER,      x  60. 

The  section  is  to  the  right  of  the  ulcerated  surface,  and  shows  the  skin  being 
undermined.  Note  the  columnar  arrangement  of  the  peripheral  cells  of  the 
neoplasm.  Between  the  epidermis  and  the  growth  is  a  layer  of  infiltrated  hyaline 
connective  tissue,  with  dilated  blood-vessels. 

cylindrical,  with  their  oval  nuclei  arranged  with  the  long  axis  perpen- 
dicular. Thin  gives  the  following  distinguishing  features : — In  rodent 
ulcer  the  nucleus  of  the  cells  is  fairly  uniform  in  size,  the  cell  proto- 
plasm is  scanty  and  not  granular,  and  the  cell-wall  is  not  discernible  ; 
further,  the  cells  never  enlarge  into  the  flat  horny  cells  of  epithelioma, 
they  never  become  prickle-cells,  never  form  nests,  do  not  retain  the  dye 
of  eosin,  soften  in  the  centre  of  the  cell  masses  by  mucoid  degeneration, 
and  the  cell  infiltration  and  disorganisation  of  the  corium  are  much 
less  than  in  epithelioma,  while  the  cell  infiltration  and  mitoses  do  not 
go  far  beyond  the  cell  growth. 

Tumours  of  the  rodent-ulcer  type  are  probably  much  commoner 


24  THE    PATHOLOGY   OF   THE   EYE 

in  the  lids  than  true  epitheliomata.  My  experience  in  this  respect 
agrees  with  that  of  Mayeda.  Between  the  two  extremes — them- 
selves not  very  far  apart — of  typical  epithelioma  and  typical  rodent 
ulcer,  there  are  tumours  which  show  characteristics  of  each,  but 
are  on  the  whole  more  nearly  allied  to  the  glandular  type  of  car- 
cinoma (Fig.  n).  In  these  the  cells  are  cylindrical  at  the  peri- 
phery, oval  or  spindle-shaped,  and  irregular  at  the  centre.  They  are 
arranged  in  columns,  within  which  the  individual  cells  may  form 
rosette-like  groups,  sometimes  with  a  lumen,  which  may  contain  secre- 
tion. There  may  he  large  nests  of  cells  with  a  central  cavity,  but 
cornification  of  the  cells  is  absent.  The  growths  seldom  extend  deeply 
into  the  tissues,  and  have  the  prolonged  course  of  rodent  ulcer.  Often 


FIG.  ii. — RODENT  ULCER  OF  LID.      x  60. 

This  part  of  the  section  shows  a  somewhat  alveolar  arrangement,  strongly 
indicating  the  origin  of  the  growth  from  glandular  tissue.  In  the  lower  part  there 
is  round-celled  infiltration.  Other  parts  of  the  growth  showed  the  more  usual 
characteristics  of  rodent  ulcer. 

the  sebaceous  glands  and  hair-follicles  around  the  growth  are  con- 
nected with  it  by  strands  of  carcinomatous  cells.  Most  of  the  tumours 
are  certainly  independent  of  the  Meibomian  glands,  but  it  is  most 
likely  that  they  originate  in  the  glands  of  the  skin. 

BOWLBY  AND  OTHERS.— Path.  Soc.  Trans.,  xlv,  1894.     THIN.— Cancerous  Affections  of 
the  Skin,  London,  1886.     *MAYEDA. —  B.  z.  A.,  Ivi,  1903. 

TUMOURS  OF  THE  GLANDS  OF  THE  LIDS 

Milium  is  often  seen  upon  the  lids,  and  when  multiple  may  be  mis- 
taken for  xanthelasma.  They  are  small,  pearly-white,  sebaceous  tumours, 


THE    LIDS  25 

and  are  supposed  to  be  retention  cysts  of  sebaceous  glands.  They 
contain  epithelial  cells,  which  may  be  horny  or  fatty,  and  are  rolled 
together  into  balls. 

Sebaceous  cysts  occur  here  as  elsewhere  in  the  skin.  The  wall 
consists  of  connective  tissue  lined  with  flat  cells,  which  show  fatty  and 
atheromatous  changes.  The  contents  are  epithelial  cells  and  fatty 
granules,  and  cholesterin  is  usually  present. 

Cysts  of  Moll's  glands  occur  as  small  transparent  cysts  at  the 
edge  of  the  lid.  They  are  retention  cysts,  and  therefore  allied  to 
sudamina  or  miliaria. 

The  outer  wall  of  the  cysts  consists  of  fibrous  tissue,  in  which  a 
few  fine  blood-vessels  and  striped  muscle-fibres  are  embedded ;  it  is 
therefore  really  the  stretched  superficial  layer  of  integument,  the 
papillae  being  flattened  out  and  lost,  whilst  any  hair-follicles  present 
are  atrophic  and  extended  over  the  convexity  of  the  cyst.  The  inner 
wall  consists  of  epithelium  lying  on  a  layer  of  unstriped  muscle-fibres, 
which  show  that  the  cysts  are  derived  from  Moll's  glands  and  not  from 
ordinary  sweat-glands,  which  do  not  possess  this  smooth  musculature 
(Sattler1).  The  epithelium  is  of  two  kinds.  In  the  multilocular  cysts, 
which  are  derived  from  the  gland  tubules,  the  epithelium  consists  of 
short  cubical  cells  in  a  single  layer.  In  the  unilocular  cysts,  which  are 
derived  from  the  gland  ducts,  there  is  a  double  or  treble  layer  of 
epithelium  consisting  of  flat  cells  with  the  long  axes  of  the  oval  nuclei 
arranged  horizontally,  the  cell  walls  being  indistinguishable.  Here  the 
cells  lie  directly  on  the  connective  tissue,  and  there  are  no  smooth 
muscle-fibres.  The  cysts  contain  a  clear  fluid,  fairly  rich  in  proteids. 
Under  the  microscope  fine  crystals  are  seen.  Wedl  and  Bock  found 
cholesterin  crystals,  Wintersteiner  calcium  sulphate ;  the  latter  is  in- 
teresting in  that  sulphates  are  contained  normally  in  sweat. 

Proliferation  of  the  walls  of  Moll's  cysts  may  produce  more  or  less 
solid  tumours,  which  form  a  connecting  link  with  the  true  adenomata. 
Wintersteiner  has  described  a  cystadenoma  papillare  proliferum  of  a 
Moll's  gland  from  the  vicinity  of  the  lower  punctum.  The  wall  was 
covered  by  a  single  layer  of  flattened  epithelium,  which  had  proliferated 
in  one  part  and  formed  a  papillomatous  projection  into  the  cavity,  thus 
very  much  resembling  many  ovarian  cysts.  This  case  appears  to  be 
unique  in  the  literature. 

Retention  cysts  of  the  Meibomian  glands  occur  very  rarely.  In 
a  case  of  Wintersteiner's  the  cyst  was  lined  by  flattened  epithelium, 
mostly  in  a  single  layer,  which  lay  upon  dense  thick  fibrous  tissue,  the 
enormously  stretched  and  thinned  tarsus.  The  .skin  was  extended 
over  the  anterior  surface,  the  papillae  being  flattened  out  and  the 
muscles,  etc.,  compressed  and  degenerated.  The  cyst  contained 
fibrinous  coagulum  and  granular  debris.  Such  cysts  have  been  pro- 
duced artificially  by  Deyl  by  obliteration  of  the  ducts  through  cicatrisa- 
tion. This  occurs  frequently  in  the  human  subject  in  trachoma,  and 
is  by  far  the  commonest  cause  of  Meibomian  cysts. 

1  SATTLER,  Arch.  f.  mikr.  Anat,  xiii. 


26  THE    PATHOLOGY   OF   THE   EYE 

DESFOSSES.— A.  d'O.,  i,  1881.     WEDL  AND  BOCK. — Path.  Anat.  des  Auges,  Wien,  1886. 
WINTERSTEINER. — A.  f.  A.,  xxxiii,  Erganzungsheft,  1896;  A.  f.  A.,  xl,  1899. 

Adenomata  have  been  described  in  connection  \\ith  the  sweat-glands 

Fuchs),   sebaceous   glands    (Fuchs,    Rumschewitsch),    Moll's    glands 

(Salzmann),     Meibomian    glands     (Baldauf,    Bock,    Rumschewitsch, 


FIG.  12. — ADENOMA  OF  MEIBOMIAN  GLAND.     Reichert  Obj.  2. 
After  Salzmann  (A.  f.  A.,  xxii,  Taf.  iv),  showing  capsule,  septa,    and    solid 
glandular  cords,  separated  from  the  septa  by  lymph  spaces. 

Salzmann,  Wadsworth,  Knapp),  Waldeyer's  glands  (Rumschewitsch), 
and  Krause's  glands  (Moauro,  Salzmann — see  "Conjunctiva").  The 
exact  origin  of  these  tumours  is  seldom  beyond  dispute.  A  few  others 
have  been  collected  by  Schirmer. 

Meibomian  adenomata   (Figs.   12  and  13)  are  possibly  commoner 


FIG.  13. — ADENOMA  OF  MEIBOMIAN  GLAND.     Reichert  Obj.  8 a. 
After  Salzmann.     From  the  middle  of  the  tumour,  showing  septa,  with  lymph 
spaces  lined  in  places  by  endothelial  cells,  and  the  pathological  gland-cells. 

than  the  literature  would  lead  one  to  expect.  It  is  not  unusual  to  meet 
with  chalazia  which  are  hard  and  do  not  respond  to  the  usual  treatment. 
It  is  possible  that  some  of  these  are  really  adenomata.  Those  which 


THE    LIDS 


27 


have  been  described  consist  of  acini  ofvery  various  sizes,  mostly  filled  with 
cells,  the  peripheral  ones  being  cylindrical,  the  central  ones  polygonal. 
There  is  rarely  a  small  lumen.  The  peripheral  cells  show  no  fatty 
vacuoles,  whilst  the  central  ones  are  usually  fatty  and  have  no  nuclei. 
The  acini  are  separated  by  connective  tissue  containing  blood-vessels, 
the  adventitiae  of  which  are  sometimes  infiltrated  with  cells  (Bock). 

Adenomata  of  Moll's  glands  (Fig.  14)  seem  to  tend  much  to  cystic 
formation,  which  was  present  in  Salzmann's  case,  and  extreme  in 
\Yintersteiner's  (v.  p.  25).  In  Salzmann's  case  there  was  a  large 
dendritic  mass  of  tubular  character,  with  a  central  cystic  space.  The 
cavity  and  tubules  were  lined  with  a  double  layer  of  cells — outer,  low, 
cubical ;  inner,  cylindrical.  There  were  no  smooth  muscle-fibres 
around  the  tubules,  as  in  the  normal  gland. 

Adenomata  of  Krause's  glands  (Fig.  15}  show  branched  and  anasto- 


FIG.  14. — ADENOMA  OF  MOLL'S  GLAND.     Reichert  Obj.  4. 

After   Salzmann.       From    the    periphery    of    the   tumour,    showing   branched 
glandular  tube,  with  regular  double  lining  of  epithelium. 

mosing  tubules  lined  with  a  single  layer  of  cubical  or  cylindrical  cells  ; 
in  places  a  second  layer  of  irregular  cells  lies  on  the  inner  surface.  The 
lumen  varies  much  in  width,  and  often  contains  degenerated  cells  and 
granular  debris.  The  stroma  consists  of  loose  connective  tissue, 
sharply  distinguished  from  the  capsule  of  the  tumour,  which  is  formed 
out  of  the  tarsal  tissue. 

FUCHS. —  A.  f.  O.,  xxiv,  2,  1878.  RUMSCHEWITSCH. — K.  M.  f.  A.,  xxviii,  1890;  x\,'igo2. 
BALDAUF. — Inaug.  Diss.,  Miinchen,  1876.  BOCK. — Wiener  klin.  Woch.,  1888.  SCHIRMER. — 
A.  f.  O.,  xxxviii,  i,  1891.  *SALZMANN.  — A.  f.  A.,  xxii,  1891.  MOAURO. — Riv.  internaz.  di 
Med.  e  Chir.,  iv,  Napoli,  1887.  WADSWORTH.—  T.  Am.  O.  S.,  1895.  *KNAPP.— T.  Am.  O.  S., 
1901. 

Syringo-adenoma  (Unna)  is  an  excessively  rare  disease  of  the  skin, 
which  has  been  observed  in  the  lids  (Jarisch).  It  consists  of  cysts  lined 


» 


28  THE    PATHOLOGY    OF   THE   EYE 

by  flat  nucleated  epithelium,  and  from  these,  duct-like  cylinders  of 
epithelial  cells  of  about  the  thickness  of  a  sweat-gland  duct  proceed. 

It  is  probably  developed  from  "  rests  " 
^  .  of  sweat-glands  (Torok),  but  the  most 

^     >•  ^  various  explanations  have  been  brought 

forward. 

RADCLIFFE-CROCKER.  —  Diseases  of  the  Skin, 
London, 1903. 

Carcinoma  of  the  Meibomian 
glands  has  been  reported  and  figured 
~''4j  by  Panas.  Some  of  the  acini  were 
normal,  whilst  others  were  filled  with 
cells  of  epitheliomatous  type,  some 
forming  concentric  nests  with  mucoid 
degeneration  in  the  centre.  Other 
cells  contained  inclusions  resembling 
coccidia. 

Fuchs  has  described  a  carcinoma 
of  the  Meibomian  or  of  Krause's  glands 
which  invaded  the  tarsus,  the  latter 

showing  hyaline  degeneration. 

„,«  Cases  are  also  reported  by  Snell, 

and   Scott   and    Griffith.      The   latter 
was    a    typical    alveolar     carcinoma, 

FIG   ^.-ADENOMA  OF  KRAUSE'S         th  n      showjng    great    diversity    of 

GLAND.     Reichert  Om.  oa.  _  ,     J... 

After    Salzmann.     The    epithelium,  character.      Some    were    exactly   like 
double  in  places,  is  seen  lying  on  the  sebaceous    epithelium,    and    in    some 

stroma,  the  lumen  containing  epithelial  sections  of  the  Meibomian  glands  the 
cells land  debris.  On  the  left  above,  are  celjs  had  perforated  the  basement 
epithelial  processes  cut  longitudinally  and  .  ,  , .  , 

transversely.  membrane  and  were  invading  the 

tarsus. 

An  adeno-carcinoma  of  the  Meibomian  glands  has  been  published  by 
v.  Grosz,  and  a  similar  one  by  Snell. 

It  is  possible  that  carcinoma  occasionally  starts  in  other  glands  of 
the  skin  and  lids.  Some  rodent  ulcers  show  a  glandular  type  of 
carcinoma  in  places  (v.  p.  24). 

PANAS. — Traite  des  Maladies  des  Yeux,  ii,  Paris,  1894.  FUCHS. — A.  f.  O.,  xxiv, 
2,  1878.  v.  GROSZ. — C.  f.  A.,  xx,  1896.  SNELL. — T.  O.  S.,  xvi,  1896.  SCOTT  AND  GRIFFITH. 
— T.  O.  S.,  xx,  1900. 


CONGENITAL  TUMOURS 

Congenital  tumours  are  nsevi  and  dermoids. 

Naevi,  or  moles,  usually  pigmented,  have  exactly  the  same  structure 
histologically  as  those  of  the  conjunctiva,  and  are  fully  dealt  with  under 
that  heading. 

Dei-moid  cysts  are  really  orbital  tumours  which  press  forward  the 
lid,  and  will  be  considered  under  "  Tumours  of  the  Orbit." 


THE    LIDS  29 

Solid  dermoids  also  occur,  and  cases  described  as  supernumerary 
caruncle  probably  belong  to  this  group  (Eyre,  Stephenson).  In  Eyre's 
case  the  tumour  occupied  the  space  between  the  upper  punctum 
lacrymale  and  the  inner  canthus.  It  was  covered  by  stratified 
epithelium,  and  contained  hair-follicles,  sebaceous  and  mucous  glands, 
and  striped  and  smooth  muscle. 

EYRE. — A.    of   O.,   xxvi,   1897  ;    T.  O.  S.,    xviii,    1898.     STEPHENSON. — Ophth.    Rev., 


CHAPTER    II 
THE     CONJUNCTIVA 

THE    NORMAL    CONJUNCTIVA 

THE  conjunctiva  is  a  mucous  membrane  covering  the  margin  and 
posterior  surface  of  the  lids,  and  reflected  on  to  the  globe.  In  the 
cornea  it  is  represented  by  the  epithelium,  so  that  it  may  be  regarded 
as  a  sac,  open  only  in  front  at  the  palpebral  aperture. 

It  is  divided  anatomically  into  three  parts  :  (i)  the  C.  palpebrarum, 
subdivided  into  a  marginal  part,  a  tarsal  part  (C.  tarsi),  and  an  orbital 
part;  (2)  the  fornix,  or  C.  fornicis;  (3)  the  C.  bulbi.  Histologically 
it  consists  of  two  layers :  (i)  the  epithelium ;  (2)  the  substantia 
propria. 

The  epithelium  varies  in  different  parts  of  the  conjunctiva  and  at 
different  ages.  It  is  only  found  typically  developed  in  the  new-born 
infant.  This  is  accounted  for  by  the  fact  that  the  irritating  effects  of 
dust,  etc.,  soon  leave  their  mark  and  are  ineradicable.  There  is, 
however,  a  fundamental  difference  in  different  parts,  and  this  manifests 
itself  in  the  specific  character  of  various  pathological  conditions,  and 
in  their  punctilious  limitation  to  definite  areas. 

The  intermarginal  /one  of  the  lid  between  the  anterior  and  poste- 
rior borders  (v.  p.  2)  is  covered  with  stratified  epithelium,  and  this 
passes  upwards  for  a  short  distance  on  to  the  posterior  surface  of  the 
lid.  This  part  of  the  lid  is  in  closest  apposition  with  the  globe,  and 
mutual  pressure  of  the  two  may  perhaps  be  the  cause  of  the  flattening 
of  the  superficial  cells.  It  ceases  in  a  line  parallel  with  the  posterior 
oorder  of  the  lid,  which  shows  a  slight  depression  and  is  called  the 
sulcus  subtarsalis.  The  cells  of  the  middle  layers  of  the  intermarginal 
zone  are  prickle-cells,  so  that  the  epithelium  resembles  epidermis 
histologically  rather  than  mucous  membrane.  There  is  therefore  little 
more  reason  for  calling  this  conjunctiva  than  skin.  It  is  a  true  transi- 
tion zone. 

The  C.  palpebrarum  is  covered  with  two  layers  of  epithelium — a 
superficial  cylindrical,  and  a  deep  flattened.  The  superficial  cells  are 
tall,  cylindrical  or  pyramidal,  with  oval  nuclei,  the  long  axes  of  which 


THE    CONJUNCTIVA  31 

coincide  with  those  of  the  cells.  The  nucleus  usually  lies  near  the 
base  of  the  cell ;  it  stains  faintly  with  haematoxylin.  The  cytoplasm 
is  copious  and  finely  granular.  The  cells  are  united  by  a  minimum  of 
cement  substance,  which  stains  with  silver  nitrate.  The  bases  of  the 
cells  are  often  separated  by  minute  spaces.  The  deep  cells  are  flat, 
with  oval  nuclei,  directed  horizontally  and  staining  deeply.  This  double 
layer  of  cells  is  only  found  on  the  C.  tarsi,  and  even  here  intercalated 
cells  are  not  uncommon,  leading  to  a  triple  lamination.  This  tendency 
increases  in  the  orbital  part  and  fornix,  and  reaches  its  maximum  at  the 
limbus,  where  the  epithelium  is  definitely  stratified.  In  this  manner 
a  middle  layer  is  gradually  formed.  The  cells  of  which  it  is  formed 
most  resemble  the  deeper  cells,  but  are  larger,  polygonal  by  mutual 
pressure,  separated  only  by  cement  substance,  and  provided  with 
centrally  situated  round  or  oval  nuclei.  As  the  limbus  is  approached 
the  basal  cells  become  more  cubical,  and  finally  cylindrical,  whilst  the 
superficial  cells  become  flatter.  At  the  limbus  the  superficial  layer 
consists  of  one  or  two  layers  of  flat  cells  with  well-marked  horizontal 
oval  nuclei ;  the  middle  layer  of  many  layers  of  polygonal  cells,  which 
are  distinguished  from  the  adjacent  corneal  cells  by  the  absence  of 
prickles,  cement  substance  alone  uniting  them  ;  the  basal  layer  of  a 
single  layer  of  small  cylindrical  or  cubical  cells,  with  large,  darkly 
staining  nuclei  and  little  cytoplasm,  often  containing  pigment  granules. 
True  papillae  are  found  at  the  limbus  (Ciaccio,  Nakagawa),  i.  e.  finger- 
like  extrusions  of  the  substantia  propria,  the  interspaces  of  which  are 
filled  with  epithelium,  whilst  the  surface  of  the  epithelium  remains  flat. 
There  are  usually  only  four  or  five  large  papillae  (50  fj.  high)  near  the 
cornea,  and  three  or  four  smaller  ones  (13 — 32  n  high)  more  peripherally 
(Villard). 

Goblet-cells  are  found  normally  in  the  epithelium  of  the  whole  con- 
junctiva, but  especially  in  that  of  the  C.  bulbi  and  fornix  (Fig.  16).  They 
much  resemble  the  goblet-cells  of  the  intestine,  but  show  interesting 
peculiarities.  In  the  fresh  state  they  are  large  round  or  oval  cells, 
strongly  refractile,  and  much  like  fat-cells.  They  are  found  at  various 
depths,  the  deeper  ones  being  smaller  and  round,  the  superficial  ones 
oval  and  larger  than  the  epithelial  cells  (25^  by  16  /u  [Green]),  and 
possessing  a  definite  opening  or  stoma  upon  the  surface.  They  have  a 
double-contoured  membrane  or  theca  (Green),  and  a  pointed  process 
below,  which  often  reaches  down  to  the  basement  membrane  (Peters). 
The  main  contents  of  the  cell  consist  of  mucin,  which  forms  homo- 
geneous or  finely  granular  droplets  when  fresh,  and  larger  granules  or 
networks  when  hardened.  This  secretion  pushes  aside  the  cytoplasm, 
which  is  almost  invisible,  and  the  flattened  nucleus  forms  a  crescent  at 
the  base.  The  latter  may  be  apparently  absent  in  thin  sections  owing  to 
the  size  of  the  cells.  Only  the  superficial  cells  have  a  stoma,  and  the 
mucin  is  often  seen  protruding  from  it.  The  stomata  are  well  displayed 
in  surface  preparations  when  the  outlines  of  the  neighbouring  cells  are 
marked  out  by  silver  staining  (Greeff).  The  secretion  stains  very 
variously.  It  is  more  or  less  extracted  during  the  process  of  hardening, 
unless  fixed  by  acetic  acid,  and  even  then  stains  variously,  owing 
probably  to  the  presence  of  intermediate  products  (mucinogen).  The 


32  THE    PATHOLOGY    OF   THE   EYE 

fresh  mucin  usually  stains  with  hsematoxylin  and  basic  aniline  dyes — 
best»with  thionin.  The  superficial  cells  give  the  best  thionin  reaction, 
owing  to  the  greater  quantity  of  the  final  product  (mucin)  present. 

Leydig  (1857)  first  discovered  such  cells  in  the  epidermis  of  the  fish, 
and  called  them  "mucous  cells"  (Schleimzellen).  They  were  called 
"goblet-cells"  (Becherzellen)  by  Schulze  (1863),  as  it  was  doubtful  if 
they  all  contained  mucin.  Stieda  (1867)  first  found  them  in  the  con- 
junctiva, and  called  them  "unicellular  mucous  glands."  Waldeyer 
(1874)  adopted  this  idea,  pointing  out  the  tendency  of  the  cylinder-cells 
to  become  metamorphosed  into  goblet-cells.  Now  these  cells  are 
found  in  far  greater  numbers  in  conditions  of  chronic  inflammation,  so 
that  Sattler  (1877)  looked  upon  them  as  pathological.  They  are  also 
more  numerous  in  tumours  (papillomata,  etc.).  Since,  however,  they 


FIG.  16. — GOBLET-CELLS  IN  THE  CONJUNCTIVA,      x  120. 

Goblet-cells,  with  the  nuclei  pressed  down  to  the  base,  are  seen  in  all  the  layers 
of  the  epithelium.  Below  is  slight  lymphocytic  infiltration,  evidence  of  chronic 
irritation.  There  is  also  a  dilated  lymphatic  space  filled  with  hyaline  material. 


occur  in  the  foetus  and  new-born,  and  were  found  by  Green  in  thirty 
consecutive  normal  conjunctive,  they  may  be  regarded  as  normal, 
though  subject  to  great  and  even  enormous  increase  under  pathological 
conditions.  Stieda,  in  1890,  altered  his  previous  opinion  that  they 
were  secretory  cells,  and  regarded  them  as  degenerated  cells.  It  seems 
probable,  indeed,  that  the  cells  are  destroyed  after  they  have  expelled 
their  contents,  secretory  activity  ending  in  destruction  ;  and  in  this 
respect  they  may  be  compared  with  the  cells  of  the  active  mammary 
gland.  Though  resembling  the  goblet-cells  of  the  intestine,  they  are 
not  identical  with  them.  The  latter  are  formed  only  upon  the  surface, 
and  regenerate  after  expelling  their  contents.  The  former  are  much 
more  nearly  allied  to  the  epiblastic  cells  described  by  Leydig  in  fishes 
and  the  larvae  of  amphibia  (Pfitzner).  They  are  apparently  formed 


THE  CONJUNCTIVA 


33 


only  from  the  cylindrical  cells,  i.  e.  mostly  from  the  deepest  layer,  remain 
closed  as  they  pass  towards  the  surface,  still  retaining  a  filamentary 
connection  with  the  basement  membrane,  and  finally  open  upon  the 
surface,  expelling  their  contents,  thereby  being  destroyed.  Their 
function  can  hardly  be  considered  doubtful.  They  are  true  uni- 
cellular mucous  glands,  moistening  and  protecting  the  conjunctiva  and 
cornea,  so  that  even  extirpation  of  the  lacrymal  gland  is  innocuous ; 
whilst,  on  the  other  hand,  xerosis  of  the  conjunctiva,  involving  their 
destruction,  leads  to  desiccation  in  spite  of  a  copious  flow  of  tears 
(Greeff). 

We  have  seen  that  true  papillae,  in  which  the  surface  epithelium 
remains  level,  only  occur  near  the  limbus.  Papillae  are  described  in 
other  parts  in  pathological  conditions ;  they  are  not  true  papillae,  how- 
ever, but  undulations  produced  by  swellings  in  the  substantia  propria. 
Similarly  depressions  in  the  surface  have  been  described  as  glands. 
The  conjunctival  surface  is  only  smooth  in  new-born  infants  (Stieda, 
Sattler,  Raehlmann,  etc.),  i.e.  before  the  adenoid  tissue  is  developed  in 


FIG.  17. — HENLE'S  GLANDS. 
From  a   photograph  by   Lister. 

the  substantia  propria.  C.  Krause  (1842),  Gerlach  (1852),  and  Kolliker 
(1863),  in  their  text-books  of  anatomy,  described  the  papillary 
nature  of  the  conjunctiva,  and  even  the  presence  of  small  mucous 
glands  (Krause).  Henle  (1866),  in  his  text-book,  regarded  the  tops  of 
the  "papillae"  as  the  normal  level,  and  described  the  depressions  as 
glands,  which  have  since  been  known  as  Henle  s  glands  (Fig.  17).  They 
consist  of  depressions  in  the  basement  membrane,  some  vertical,  others 
oblique,  of  various  length,  lined  by  regular  cylindrical  epithelium. 
Stieda  first  cut  sections  parallel  to  the  surface,  and  found  that  the  so- 
called  glands  were  not  regular  tubular  depressions,  but  folds  and 
furrows  (Stieda's  '  Rinnen  und  Falten-system '),  having  round  or  irregular 
contours  of  various  sizes.  In  sections  in  other  directions  these  are  cut 
across  so  as  to  produce  the  most  various  appearances,  much  resembling 
true  glandular  structures.  They  are  naturally  most  marked  in  the 
central  parts  of  the  upper  fold,  especially  near  the  upper  part  of  the 
tarsus,  gradually  fading  off  towards  the  canthi.  The  cylindrical  shape 
of  the  cells  is  characteristic  of  all  depressions,  where  the  epithelium  is 
less  exposed  to  pressure.  True  tubular  glands  are  normally  present 

3 


34  THE    PATHOLOGY   OF   THE    EYE 

just  beyond  the  limbus  in  the  calf  and  ox  (Meissner),  and  in  the  pig 
(Manz).  The  presence  of  tubular  glands  in  the  C.  tarsi  is  doubtful. 
Tubular  depressions,  however,  do  occur,  which  cannot  be  fully 
explained  by  folds  (Stieda,  Jacobson,  Sattler),  especially  in  the  nasal 
parts  of  the  lid  (Baumgarten's  tubular  glands). 

True  large  acino-tubular  glands  (Krause's  glands,  accessory  lacrymal 
glands)  occur  below  the  surface  between  the  fornix  and  the  edge  of  the 
tarsus,  especially  towards  the  nasal  side.  There  are  about  forty-two 
in  the  upper,  and  six  to  eight  in  the  lower  fornix  (W.  Krause).  They 
are  serous  glands,  exactly  resembling  the  lacrymal  gland,  and,  indeed, 
forming  offshoots  of  the  inferior  lacrymal  gland.  The  ducts  of 
numerous  acini  unite  to  form  a  larger  duct  which  opens  on  to  the 
fornix. 

The  substantia  propria  consists  of  adenoid  connective  tissue.  The 
reticulum  of  fibrous  tissue  contains  many  lymphocytes  in  its  meshes, 
especially  in  the  superficial  layers,  so  that  a  division  is  sometimes  made 
into  a  superficial  adenoid  layer  and  a  deep  fibrous  layer.  The  adenoid 
layer  is  absent  in  the  new-born,  and  commences  two  or  three  months 
after  birth  by  the  invasion  of  the  fibrillary  tissue  at  certain  spots  in 
the  fornix  (Raehlmann).  It  is  the  development  of  this  layer,  accom- 
panied by  increase  in  the  superficial  area,  which  leads  at  about  the  end 
of  the  fifth  month  to  the  formation  of  folds  in  the  upper  third  of  the 
C.  palpebrarum  (Raehlmann). 

The  adenoid  layer  is  thin,  but  varies — 40  /u  in  the  C.  palpebrarum, 
50 — 70  ju  in  the  fornix,  15 — 27  /u  in  the  C.  bulbi  (Villard).  It  ceases  at 
the  sulcus  subtarsalis,  and  is  therefore  absent  under  the  stratified 
epithelium  from  that  line  to  the  anterior  border  of  the  lid.  The 
meshes  consist  of  extremely  fine  fibres.  The  lymphocytes  are  usually 
numerous  in  all  parts,  even  in  quite  normal  conjunctive,  but  are 
enormously  increased  in  conjunctivitis.  They  are  usually  distributed 
regularly,  but  much  discussion  has  arisen  as  to  whether  follicles 
normally  occur  (see  "  Trachoma ").  They  are  constant,  especially 
near  the  lower  fornix,  in  many  animals  (dog,  cat,  rabbit,  etc.). 
Nodules  of  lymphocytes  are  frequently  found  in  the  human  conjunctiva, 
but  they  usually  fade  off  at  the  periphery,  and  do  not  form  true 
follicles.  The  pathological  development  of  these  follicles  leads  to 
undulations  in  the  surface — pseudo-papillae. 

The  fibrous  layer  is  thicker  than  the  adenoid,  and  composed  of 
thicker  meshes,  which  contain  many  elastic  fibres.  The  density  of 
this  layer  offers  great  obstacles  to  cellular  infiltration.  The  layer  is 
thin  over  the  tarsus,  with  which  it  is  continuous.  In  other  parts  it  is 
looser.  The  posterior  insertion  of  the  levator  palpebrae  fades  off 
into  it  at  the  fornix,  which  is  thus  lifted  up  in  upward  movements  of 
the  lid. 

The  chief  arteries,  veins,  lymphatics,  and  nerves  lie  in  the  fibrous 
layer,  but  the  adenoid  layer  is  very  richly  supplied. 

The  plica  semilunaris  is  a  simple  fold  of  the  C.  bulbi  near  the  inner 
canthus.  It  is  the  vestige  of  the  nictitating  membrane,  and  as  such 
sometimes  contains  a  small  cartilaginous  plate  (Buschmann,  Evers- 
busch)  and  an  acinous  gland  (Giacomini),  the  remnant  of  the  Harderian 


THE    CONJUNCTIVA  35 

gland.  It  has  been  found  enlarged  on  one  or  both  sides  in  a  few  cases, 
resembling  the  true  nictitating  membrane  (Herzenstein,  Eversbusch), 
or  hypertrophied  into  a  tumour  (Rumschewitsch).  It  is  doubtful  if 
these  were  true  hypertrophies. 

The  caruncle  is  an  outlying  patch  of  skin,  the  epithelium  of  which 
has  become  modified  by  environment,  having  two  layers  like  the 
C.  tarsi,  increased  by  several  middle  layers  on  the  summit.  Goblet- 
cells,  glandular  depressions,  and  fine  hairs  with  sebaceous  glands  are 
always  present.  Glands  resembling  Krause's  glands  are  present 
(Krause,  Giacomini,  etc.),  and,  according  to  some  authors,  sweat- 
glands  (Waldeyer,  Sattler,  Rumschewitsch).  There  are  fat  globules  in 
the  corium. 

CIACCIO. — Mem.  de  1'Acad.  des  Sc.  de  1'Institut  de  Bologne,  1873.  NAKAGAWA. — 
A.  f.  A.,  xlvii,  1903.  VILLARD. — Anat.  path,  de  la  Conjonctive  granuleuse,  Paris,  1896. 
*GREEN. — A.  f.  O.,  xl,  i,  1894.  PETERS. — C.  f.  A.,  xxi,  1897.  STIEDA. — Arch.  f.  mikr. 
Anat.,  iii,  1867.  WALDEYER.— In  G.-S.,  i,  1874.  REICH. — A.  f.  O.,  xxi,  i,  1875.  SATTLER. 
— A.  f.  O.,  xxiii,  4,  1877.  WOLFRING. — K.  M.  f.  A.,  1878,  Beilageheft.  JACOBSON. — A.  f.  O., 
xxv,  2,  1879.  BAUMGARTEN. — A.  f.  O.,  xxvi,  i,  1880.  RAEHLMANN. — A.  f.  O.,  xxix,  2, 
1883.  WALDEYER. — In  de  Wecker  and  Landolt,  Traite,  ii,  Paris,  1886  (Bibliography). 
STIEDA. — Arch.  f.  mikr.  Anat.,  xxxvi,  1890.  TERSON. — A.  d'O.,  xii,  1892.  PFITZNER. — 
Zeitschrift  f.  Biologic,  xxxiv,  1896.  *GREEFF.  —  In  Orth,  Lehrbuch  d.  spec.  path.  Anat., 
1902.  BUSCHMANN. — Arch.  ital.  de  Biol.,  ix,  1887.  GIACOMINI. — Annotazioni  sopra  1'Anat. 
del  Negro,  Torino,  1878.  HERZENSTEIN. — Centralbl.  f.  d.  med.  Wissensch.,  1879. 
EVERSBUSCH. — Festschrift  des  Munch.  Aerztevereins,  1883.  RUMSCHEWITSCH. — K.  M.f.  A., 
xl,  1902  ;  xli,  1903. 


THE    BACTERIOLOGY   OF   THE   CONJUNCTIVA 

THE  NORMAL  CONJUNCTIVA 

The  normal  conjunctiva  in  the  new-born  is  free  from  bacteria. 
Koblank  investigated  this  point  in  twenty  cases  by  culture  experiments, 
which  were  negative.  He  attributes  it  to  the  fact  that  the  lids  remain 
closed  intra-partum.  Cramer  proved  that  they  may  open.  In  some 
cases  xerosis  bacilli  and  staphylococci  were  found  on  the  second  day  ; 
in  others  the  conjunctiva  was  still  sterile  on  the  sixth  day.  In  any 
case  the  bacteria  are  few  during  the  first  ten  days. 

WALTHARD. — In  Pfliiger,  Korrespondenzbl.  f.  Schweizer  Aerzte,  1895.  KOBLANK. — 
Festschrift  f.  Karl  Ruge,  Berlin,  1898.  CRAMER. — Centralbl.  f.  Gynakologie,  No.  9,  1899. 

The  conjunctival  sac  is  open  to  the  air,  and  is  in  intimate  proximity 
to  the  skin.  It  is  not  surprising,  therefore,  that  it  should  contain 
many  bacteria  from  both  of  these  sources.  It  is  more  surprising  that 
so  large  a  proportion  of  sterile  conjunctive  should  have  been  found  by 
various  authors  (Foote,  50  per  cent,  in  children,  33  per  cent,  in  young 
people,  30  per  cent,  in  old  people ;  Eyre,  50  per  cent.).  Still,  there  can 
be  no  doubt  that  the  number  of  organisms  varies  greatly  (Eyre), 
whilst  their  nature  and  pathogenicity,  and  the  possibility  of  sterilisation, 
are  subjects  of  much  dispute.  The  xerosis  bacillus  is  most  commonly 
found  (Heinersdorff,  Lawson,  Axenfeld  [i],  Gifford),  and  after  that  the 


36  THE    PATHOLOGY    OF   THE    EYE 

Staphylococcus  albus.  Lawson  alone  found  the  latter  seldom  (6  out  of 
200  cases).  Gasparrini  found  the  pneumococcus  in  80  per  cent,  of 
cases,  which  has  been  shown  to  be  a  mistake  by  Oertzen  (4  per  cent.). 
Lawson  found  it  twice  in  200  cases.  According  to  my  own  experience 
small  diplococci  are  not  uncommon  in  the  conjunctiva,  and  they 
probably  include  many  species,  some  of  which  have  been  mistaken 
for  pneumococci. 

The  staphylococci  found  are  usually  of  slight  virulence.  Virulent 
pyogenic  staphylococci  (aureus  and  albus),  streptococci,  etc.,  are  rare. 

The  identity  of  the  xerosis  bacillus  will  be  discussed  later. 

Other  pathogenic  and  non-pathogenic  bacteria  are  found  occasion- 
ally. In  this  connection  it  need  only  be  noted  that  Lobanow  found 
that  amongst  the  non-pathogenic  organisms  the  Sarcina  lutea,  Proteus, 
B.  subtilis,  prodigiosus,  agilis,  fluorescens,  putridus,  and  Micrococcus 
roseus,  introduced  into  the  anterior  chamber  and  vitreous  of  the  rabbit, 
produced  a  slight,  non-progressive  inflammation. 

Bach  investigated  the  influence  of  movements  of  the  lids  and  of 
tears  upon  the  bacteria.  He  showed  that  within  twenty-four  hours 
organisms  (Kiel  water  bacillus,  Staph.  pyog.  aureus)  were  transported 
from  the  conjunctiva  to  the  nose.  Transference  from  the  nose  to  the 
conjunctiva  could  never  be  obtained  with  normal  flow  of  tears  (this 
was  confirmed  by  Hauenschild).  He  confirmed  Bernheim's  dictum 
that  the  tears  were  slightly  bactericidal ;  this  is  probably  not  due  to 
serum-albumen  (Bernheim),  but  to  mere  dilution,  just  as  with  salt 
solution,  water,  etc.  (Morax,  Bach),  de  Bono  and  Frisco  inoculated 
the  tears  of  goats,  asses,  and  calves  with  Staph.  pyog.  aureus,  diphtheria 
bacillus,  etc.,  and  inoculated  culture  media  from  them  after  |,  1,4,  14, 
48  hours.  After  48  hours  the  number  of  bacteria  was  definitely 
increased,  though  a  slight  diminution  took  place  in  the  first  hour.  The 
toxicity  of  tubercle  bacilli  was  not  diminished ;  that  of  diphtheria 
bacilli  was  remarkably  so — inoculation  with  freshly  infected  tears  killed 
in  seven  days  (control  in  two  days) ;  after  six  hours  the  inoculated 
animals  did  not  die.  Whether  these  experiments  can  be  regarded  as 
true  for  man  is  doubtful ;  the  Harderian  secretion  must  be  taken  into 
account.  Axenfeld  (2)  concludes  that  the  bactericidal  property  of 
tears  is  as  yet  by  no  means  definitely  proved.  The  tears  are  doubtless 
a  bad  culture  medium  ;  many  bacteria  must  die,  but  a  definite  bacteri- 
cidal property  is  questionable. 

The  possibility  of  sterilising  the  conjunctiva  is  a  question  of  grave 
practical  importance.  Bach  showed  that  mechanical  purification  of 
the  lids,  combined  with  irrigation  of  the  conjunctiva  with  saline  solution, 
led  to  great  diminution  in  the  micro-organisms,  amounting  to  sterilisa- 
tion in  nearly  half  the  cases.  There  was  no  greater  effect  with 
antiseptics,  but  it  must  be  noted  that  perchloride  of  mercury  (i  in 
2000)  was  used  for  the  lids.  Morax,  however,  found  no  difference.  The 
importance  of  non-irritative  lotions  is  emphasised  by  many  authors. 
Widmark  found  microscopic  changes  in  the  epithelium  with  sublimate 
solutions  of  i  in  5000,  and  even  i  in  10,000.  It  is  generally  admitted 
that  complete  sterilisation  is  in  most  cases  unattainable  (Bach  [2]  for 
formol,  i  in  2000  or  3000 ;  Franke  for  sublimate,  i  in  5000  ;  Gifford, 


THE    CONJUNCTIVA  37 

McGillivray),  even  though  it  be  occasionally  attained.  Franke 
disagrees  with  Bach  and  Morax  in  that  he  obtained  better  results  with 
sublimate  than  with  saline  irrigation.  Much  doubtless  depends  upon 
mere  mechanical  details.  Hauenschild  published  statistics  of  the 
Wtirzburg  clinic  from  1893  to  1898 — 1944  operations  upon  the  globe, 
including  549  cataracts — with  asepsis  only,  and  only  one  suppuration. 
Nearly  allied  is  the  question  of  the  influence  of  bandaging  upon  the 
number  of  micro-organisms  found.  Odhelius  (1772 — 1807)  is  said  to 
have  recommended  the  open  treatment  of  wounds,  and  bandages  were 
occasionally  dispensed  with  by  Demours  and  Desmarres  (Rohmer).  It 
has  been  used  in  an  unqualified  manner  by  Hjort.  Clarke  has 
published  experiments  tending  to  show  that  the  anterior  chamber  is 
most  rapidly  refilled  in  corneal  wounds  in  rabbits  when  the  animals  are 
kept  at  rest  by 'an  anaesthetic  (five  to  fifteen  minutes),  whereas,  if  they 
are  allowed  to  recover,  the  movements  of  the  animal  so  interfere  with 
the  process  that  it  is  not  complete  for  two  hours.  This  tendency  to  a 
delayed  adhesion  of  the  lips  of  the  wound,  being  in  favour  of  infection, 
must  be  set  against  any  tendency  of  the  lid  movements,  by  increasing 
the  current  of  tears,  to  diminish  the  bacteria  in  the  conjunctival  sac. 
And,  indeed,  the  evidence  in  favour  of  the  latter  tendency  is  by  no 
means  conclusive.  Dalens  found  that  after  five  to  eight  hours'  bandag- 
ing the  bacteria  were  decidedly  fewer  than  before  disinfection  (twenty 
experiments  in  ten  people),  whilst  after  twelve  to  fourteen  hours' 
bandaging  (forty  experiments  in  twenty  people)  a  variable  result  was 
obtained — increase  in  both  eyes  in  four,  diminution  in  both  eyes  in 
seven,  and  increase  in  one  eye  with  diminution  in  the  other  in  six.  The 
indications  of  these  experiments  seem  to  be  in  favour  of  bandaging 
until  the  wound  is,  closed,  after  which  movements  of  the  lids  are  not 
harmful,  and  may  even  be  beneficial. 

PICK. — U.  die  Mikroorganismen  im  Konjunktivalsak,  Wiesbaden,  1887.  FOOTE. — 
Med.  Record,  1896.  EYRE. — Annals  of  Ophth.,  1897.  HEINERSDORFF. — A.  f.  O.,  xlvi, 
i,  1898.  LAWSON. — Brit.  Med.  Jl.,  1898.  AXEXFELD  (i). — Berlin,  klin.  Woch.,  1898. 
GIFFORD. — A.  f.  A.,  xxxix,  1899.  GASPARRINI. — Ann.  di  Ott.,  xxii,  6,  1894.  OERTZEN. — 
K.  M.  f.  A.,  xxxviii,  1899.  LOBANOW. — In  "Lubarsch  and  Ostertag,  Ergebnisse  der  allg. 
Path.,  Wiesbaden,  1901.  BACH  (i). — A.  f.  O.,  xl,  3,  1894.  DE  BONO  AND  FRISCO. — Arch, 
di  Ott.,  vii,  1899.  *AXENFELD  (2). — In  Lubarsch  and  Ostertag,  Wiesbaden,  1901.  MORAX 
— These  de  Paris,  1894.  BACH  (2).— A.  f.  A.,  xxxv,  1897.  FRANKE. — A.  f.  O.,  xliii,  i,  1897. 
MCGILLIVRAY. — Ophth.  Rev.,  xvii,  1898.  HAUENSCHILD. — Z.  f.  A.,  ii,  1899.  ROHMER. — 
Ann.  d'Oc.,  cxxi,  1890.  HJORT. — C.  f.  A.,  xxi,  1897;  xxii,  1898.  CLARKE. — T.  O.  S.,  xviii, 
1898.  DALENS. — In  Lubarsch  and  Ostertag,  Wiesbaden,  1901.  GRIFFITH. — Thompson- 
Yates  Lab.  Rep.,  iv,  1901. 

CONJUNCTIVITIS 

The  present  state  of  knowledge  unfortunately  does  not  admit  of  an 
accurate  classification  of  the  various  forms  of  conjunctivitis  upon  a 
pathological  basis.  In  only  very  few  cases  is  it  possible  to  specify  a 
definite  micro-organism  as  the  causa  causans  of  a  given  clinical  type  of 
inflammation.  Nor  is  this  surprising  when  we  consider  the  multi- 
tudinous factors  at  work.  The  interaction  and  reaction  of  organism 
and  tissue,  with  the  modifying  influences  of  toxicity  and  immunity — 
relative  or  absolute, — cannot  be  too  often  or  too  forcibly  insisted  upon. 


38  THE    PATHOLOGY   OF   THE   EYE 

The  pathologist  too  readily  imagines  that  his  experiments  in  vitro  will 
be  unchanged  in  corpore  vili,  whilst  the  clinician  expects  all  his 
difficulties  to  be  solved  by  a  film  or  a  culture-tube.  When  we  add  to 
these  distracting  factors  the  phenomena  of  mixed  infections,  the 
bewildering  complexity  of  the  subject  is  complete. 

It  is  therefore  necessary  to  treat  the  bacteriology  of  conjunctivitis 
apart  from  the  clinical  types,  and  incidentally  to  collate  the  two,  and  as 
far  as  is  possible  show  their  true  relationships.  A  valuable  brief 
resume  will  be  found  in  a  paper  by  Uhthoff  (1898),  and  most  of  the 
recent  literature  in  Lubarsch  and  Ostertag. 

*UHTHOFF. — Vossius'  Sammlung,  ii,  5, 1898.  *LUBARSCH  AND  OSTERTAG. — Ergebnisse 
der  allgemeinen  Path.  u.  path.  Anat.  des  Auges.,  Wiesbaden,  1894,  1895-6,  1897-8-9. 
*AXENFELD. — In  Kolle  and  Wassermann,  Handbuch  der  path.  Microorganismen,  Jena,  1903. 


STAPHYLOCOCCI 

Staphylococci  are  constantly  found  in  the  skin  at  the  edge  of  the 
lids,  and,  as  we  have  seen,  they  often  find  their  way  into  the  normal 
conjunctival  sac.  St.  albus  in  a  non-virulent  form  is  common ; 
St.  aureus  is  rarer.  They  have  been  wrongly  regarded  as  the  cause  of 
phlyctenular  conjunctivitis  by  many  authors  (q.  v.).  Whether  they  are 
of  aetiological  moment  in  the  cases  of  ophthalmia  neonatorum  (q.  v.) 
and  membranous  conjunctivitis  (q.  v.),  in  which  they  occur  in  large 
numbers,  is  uncertain.  It  is  doubtful  whether  an  endogenous  staphy- 
lococcic  conjunctivitis  exists,  as  has  been  described  in  measles  (Barbier, 
Cuenod)  and  other  exanthemata.  Staphylococci  have  been  most 
often  described  in  cases  of  pseudo-membranous  conjunctivitis  (Gaspar- 
rini,  Valude,  Pichler,  Bietti,  etc.).  In  man,  all  experiments  for 
producing  conjunctivitis  by  rubbing  virulent  S.  aureus  cultures  into  the 
intact  conjunctival  sac  have  hitherto  failed. 

VALUDE. — Ann.  d'Oc.,  cxi,  1894.  PICHLER.- — B.  z.  A.,  xxiv,  1896.  BIETTI. — Ann.  di 
Ott.,  xxvi,  1897  ;  K.  M.  f.  A.,  xli,  Beilageheft,  1903. 


STREPTOCOCCI 

Streptococci  never  occur  in  the  normal  conjunctiva  according  to 
most  authors  (Pick,  Marthen,  Morax,  etc.) ;  relatively  frequently 
according  to  Gasparrini,  Villeneuve,  etc. ;  rarely  according  to  Uhthoff. 
Streptococcic  conjunctivitis  occurs  in  two  chief  groups,  a  simple 
catarrhal  and  a  pseudo-membranous  form. 

The  simple  catarrhal  form  is  known  as  Parinatid's  lacrymal  con- 
junctivitis. It  is  a  rare  condition,  associated  with  dacryocystitis  ;  it  is 
often  unilateral.  The  conjunctiva,  especially  the  bulbar  conjunctiva,  is 
intensely  injected  and  moderately  thickened ;  there  is  slight  secretion, 
and  some  swelling  of  the  lids.  Iritis  is  relatively  frequent,  especially  as 
"serous"  iritis;  the  preauricular  and  cervical  glands  are  often  swollen 
and  painful,  and  there  is  a  general  febrile  condition.  Several  of  the 
cases  occurred  in  butchers,  or  people  employed  with  cattle,  so  that 
Parinaud  attributed  the  disease  to  an  animal  origin.  The  subject  has 


THE    CONJUNCTIVA  39 

been  investigated  by  Gasparrini,  Valude,  Bardelli,  Axenfeld,  Gifford, 
etc.  Most  observers  found  streptococci,  but  their  astiological  signi- 
ficance cannot  be  said  to  be  proved  beyond  cavil.  Morax  found  the 
aqueous  sterile  in  one  case,  so  that  the  irido-cyclitis  is  probably  due  to 
the  absorption  of  toxins ;  indeed,  Bardelli  succeeded  in  producing 
kerato-iritis  in  rabbits  by  repeated  irrigation  of  the  conjunctival  sac 
with  dead,  filtered  bouillon  cultures. 

The  pseudo-membranous  form  is  met  with  more  frequently  ;  Coppez 
has  collected  thirteen  cases  from  the  literature,  and  Uhthoff  has  seen 
several.  They  often  ended  with  loss  of  the  eye  through  ulceration  of 
the  cornea,  and  occasionally  in  death  of  the  patient.  Cases  of  mixed 
streptococcic  and  diphtherial  infection  are  reported  (Franke).  Strepto- 
cocci may  be  present  in  large  numbers  in  impetigo  of  the  face,  and  the 
association  of  this  condition  with  membranous  conjunctivitis  is  well 
established  (Uhthoff). 

Occasionally  endogenous  streptococcic  conjunctivitis  occurs,  accom- 
panied by  great  swelling  of  the  lids  and  moderate  secretion.  Leber  and 
Wagenmann,  and  Axenfeld  report  two  such  cases,  both  in  new-born 
children,  ending  fatally :  in  the  first  there  was  partial  necrosis  of  the 
conjunctiva ;  the  second  resembled  ophthalmia  neonatorum.  In  both 
there  were  streptococcic  thrombi  in  the  conjunctival  vessels.  In  Leber 
and  Wagenmann's  case  death  followed  the  day  after  onset  of  the 
conjunctivitis,  so  that  it  could  scarcely  be  the  primary  seat  of  infection. 

MARTHEN. — B.  z.  A.,  xii,  1895.  VILLENEUVE. — These  de  Paris,  1896.  PARINAUD. — 
Ann.  d'Oc.,  cvii,  1892.  BARDELLI. — Ann.  di  Ott.,  xiv,  1895.  AXENFELD. — Munch,  med. 
Woch.,  1898.  GIFFORD. — Amer.  Jl.  of  Ophth.,  xv,  1898.  COPPEZ. — Des  Conjonctivites 
pseudomembraneuses,  Paris  et  Bruxelles,  1897.  FRANKE. — Munch,  med.  Woch.,  1883. 
LEBER  AND  WAGENMANN. — A.  f.  O.,  xxxiv,  4,  1888.  AXENFELD. — A.  f.  O.,  xl,  3  and  4,  1894. 


THE  PNEUMOCOCCUS  (FRANKEL — WEICHSELBAUM) 

The  Diplococcus  lanceolatus  or  pneumococcus  occurs  rarely  in  the 
normal  conjunctiva.  It  has  been  the  cause  of  severe  epidemics,  both 
in  Europe  and  America,  the  organism  being  rare  only  in  Egypt.  It  is 
commonest  in  children,  and  was  first  described  by  Parinaud  and  Morax 
in  the  new-born.  It  had  been  previously  described  in  hypopyon  ulcers 
by  Gasparrini,  who  showed  that  it  produced  conjunctivitis  in  rabbits  ; 
it  is  indeed  the  cause  of  the  typical  hypopyon  ulcer — ulcus  serpens 
(Uhthoff  and  Axenfeld).  Axenfeld  investigated  an  epidemic  at  Mar- 
burg, and  confirmed  its  predilection  for  young  children.  Gifford, 
however,  in  an  epidemic  in  Omaha,  found  about  half  the  cases  in  adults. 
Junius  found  thirty-six  out  of  forty-nine  patients  young.  Gifford  was 
able  to  cultivate  the  organism,  and  reproduce  the  disease  in  men  from 
the  cultures  ;  but  pneumococcic  conjunctivitis  is  not  invariably  con- 
tagious, predisposition  on  the  part  of  the  patient  being  necessary. 
There  is  slight  rose-red  redema  at  first,  followed  by  great  swelling,  and 
occasional  formation  of  a  membrane  (Morax,  Axenfeld,  Coppez,  Pichler). 
The  secretion  is  watery,  and  small  haemorrhages  are  common,  especially 
in  the  upper  lid  (Axenfeld,  Uhthoff,  Junius).  Gifford  saw  greater  varia- 


40  THE    PATHOLOGY    OF   THE    EYE 

tion  in  the  cases.  Cases  also  occur  sporadically.  Infection  of  the 
cornea  is  rare,  since  the  toxin  has  no  effect  upon  the  intact  epithelium 
(Coppez).  Follicles  are  only  formed  rarely,  and  rapidly  disappear 
(Axenfeld,  Junius).  There  is  an  incubation  period  of  forty-eight  hours 
(Gifford). 

E.  v.  Hippel  found  pneumococci  which  were  not  virulent  to  rabbits 
in  a  case  of  congenital  purulent  conjunctivitis,  i.  e.  pus  was  present  in 
the  conjunctival  sac  at  birth. 

The  pneumococcus  is  very  wide-spread  both  geographically  and 
pathologically.  It  was  discovered  independently  in  human  saliva  in 
1 880-81  by  Sternberg  and  Pasteur.  It  was  shown  by  Frankel,  con- 
firmed by  Weichselbaum,  to  be  the  cause  of  lobar  pneumonia,  but  it 
also  occurs  in  otitis  media,  purulent  meningitis,  etc.  The  appearance 


FIG.  18. — PNEUMOCOCCI.      x  1000. 

Specimen  by  Mayou,  taken  from  conjunctival  sac;  photograph  by  Henderson. 
Cultures  were  taken  the  day  after  development  of  a  minute  corneal  ulcer ;  they 
were  virulent  for  mice. 

in  cover-glass  preparations  is  often  characteristic ;  at  other  times  it 
must  be  substantiated  by  cultures,  and  always  when  possible  by  inocu- 
lations. Stained  with  methylene  blue,  the  diplococci  have  a  typical 
lanceolate  shape,  and  are  surrounded  by  a  faintly  stained  capsule 
(Fig.  18),  which  may,  however,  be  absent  in  conjunctival  forms.  They 
often  form  short  chains  of  four  to  six  or  even  more  members.  There 
are  other  characteristics  which  tend  to  show  that  it  belongs  to  the 
Streptococcus  pyogenes  group.  If  so,  it  is  specially  differentiated,  as 
is  further  shown  by  the  difficulty  of  cultivating  it,  mucous  secretions 
being  its  normal  habitat.  It  is  stained  by  Gram's  method,  but  the 
capsule  is  then  decolourised.  The  meningococcus  is  decolourised  by 
Gram.  The  pneumococcus  grows  best  on  alkaline  media  at  35°  C., 


THE    CONJUNCTIVA  41 

forming  transparent  round  colonies.  Films  from  the  cultures  show 
no  capsules.  The  virulence  is  soon  lost  on  agar  or  blood-serum,  but  is 
retained  longer  in  bouillon.  Inoculations  of  the  fresh  bouillon  cultures 
into  guinea-pigs,  mice  or  rabbits  leads  to  death  in  twenty-four  hours 
from  septicaemia,  with  characteristic  redema  and  swelling  of  the  spleen. 
Inoculation  of  a  white  mouse  with  cultures  is  not  invariably  lethal 
even  in  typical  cases  of  conjunctivitis  (Uhthoff). 

PARINAUD. — Ann.  d'Oc.j  cxii,  1894.  MORAX. — These  de  Paris,  1894.  GASPARRINI. — 
Ann.  di  Ott.,  xxii,  1893;  xxiii,  1894;  xxv,  1896.  UHTHOFF  AND  AXENFELD. — Berl.  klin. 
Woch.,  1895  ;  A.  f.  O.,  xlii,  i,  1896.  AXENFELD. — Munch,  med.  Woch.,  1898.  GIFFORD. — 
A.  of  O.,  xxv,  1896.  JUNIUS. — Z.  f.  A.,  i,  1899.  OERTZEN. — K.  M.  f.  A.,  xxxvii,  1899. 
GoMN. — Rev.  med.  de  la  Suisse  Romande,  1899.  VEASEY. — A.  of  O.,  xxviii,  1899.  VEASEY 
AND  DE  SCHWEINITZ. — Ophth.  Rev.,  xviii,  1899.  KIBBE. — A.  f.  A.,  xxxviii,  1899.  COPPEZ. 
— Z.  f.  A.,  ii,  Beilageheft,  1899.  E.  v.  HIPPEL. — A.  f.  O.,  xlvii,  i,  1898.  PETIT. — Ann.  d'Oc., 
cxxvi,  1901.  HAUENSCHILD. — Z.  f.  A.,  Hi,  1900.  DENIG. — Z.  f.  A.,  iii,  1900.  HERTEL. — 
A.  f.  O.,  liii,  3,  1902. 

THE  GONOCOCCUS  (NEISSER) 

Gonorrhoeal  conjunctivitis  occurs  most  commonly  in  new-born 
children  as  a  severe  type  of  ophthalmia  neonatorum,  and  in  young 
adults.  It  also  occurs  as  a  metastatic  infection.  It  is  characterised 
by  an  intense  chemosis,  with  marked  papillary  development,  and  pro- 
fuse purulent  discharge.  It  is  always  acute,  never  becoming  chronic, 
but  ending  in  resolution,  most  frequently  after  partial  or  complete 
destruction  of  the  eye.  In  the  later  stages  there  is  a  marked  tendency  to 
form  a  membrane  (Streatfield,  etc.).  This  may  also  occur  in  the  early 
stages  (Uhthoff).  Follicles  are  never  formed,  and  scars  are  not  usually 
left  in  the  conjunctiva.  In  these  respects  it  differs  essentially  from 
trachoma,  though,  of  course,  each  may  be  present  independently.  The 
gonococcus  is  unique  in  its  ability  to  invade  the  normal  corneal  epi- 
thelium, especially  when  the  pus  is  allowed  to  stagnate.  This  is 
followed  by  ulceration  of  the  cornea,  and  the  dangers  of  panophthal- 
mitis. 

The  gonococcus  is  invariably  contagious,  but  it  is  remarkable  that 
the  proportion  of  persons  suffering  from  gonorrhoea  who  have  gonor- 
rhceal  ophthalmia  is  so  small.  This  is  doubtless  due  chiefly  to  the 
protection  which  the  lids  and  tears  afford,  but  it  is  possibly  also  due 
in  part  to  a  low  degree  of  immunity  conferred  by  the  disease.  Evidence, 
however,  on  this  point  is  lacking. 

Endogenous  gonorrhreal  conjunctivitis  (Haltenhoff),  and  especially 
iritis  (Cheatham,  Griffith,  Lawford),  is  now  proved.  It  has  long  been 
considered  probable  (Brandes,  1854  ;  Fournier,  1866).  Just  as  gonococci 
can  be  carried  in  the  blood-stream  to  the  joints,  and  there  set  up 
inflammation,  the  same  may  happen  to  the  eyes.  In  fact,  it  is  most 
commonly  found  in  those  cases  in  which  the  joints  are  affected.  As  in 
the  joints,  so  in  the  eyes,  gonococci  themselves  are  generally  absent ; 
they  are  probably  present  in  the  tissues,  but  not  in  the  secretions ;  but 
the  possibility  of  a  general  toxaemia,  manifesting  itself  in  weak  spots, 
must  not  be  overlooked.  Morax  found  gonococci  in  the  conjunctiva  in 
two  cases.  It  is  also  characteristic  of  these  metastatic  gonorrhceal 


42  THE    PATHOLOGY   OF   THE    EYE 

affections  that  the  urethral  lesion  is  generally  a  mixed  infection,  the 
periurethral  tissues  containing  staphylococci  and  streptococci  in 
addition  to  gonococci  (Loeb,  Koenig,  Neisser  and  Bumm).  The 
conjunctivitis  often  recurs,  not  necessarily  simultaneously  with  the 
joint  affection  (Gielen).  Metastatic  retinitis  and  optic  neuritis  have 
also  been  described. 

Metastasis  from  a  primary  gonorrhoeal  conjunctivitis  is  much  rarer, 
but  cases  have  been  proved.  They  occur  mostly  in  new-born  children, 
the  joints  being  usually  affected.  Deutschmann  and  Clement  Lucas 
found  gonococci  in  the  pus  from  the  knee  in  some  cases.  The  rarity 
is  probably  due  to  the  free  exit  of  discharge  from  the  conjunctiva  as 
compared  with  the  urethra  (Clement  Lucas).  The  literature  will  be 
found  in  Altland's  paper. 

A    rare    type    of  infection    is    intra-uterine,  either  by   endogenous 


FIG.  19. — GONOCOCCI.     x   1000. 

Specimen    by    McNab,    taken    from    conjunctival    sac,    stained    with    Unna's 
pyronin-methyl  green  mixture.     Photograph  by  Henderson. 

metastasis  by  the  blood-channels,  or  by  infection  from  the  vagina,  or 
introduced  per  vaginam  (cf.  E.  v.  Hippel).  Thus,  as  regards  endogenous 
transmission,  it  is  known  that  anthrax,  glanders,  tubercle,  typhus,  pheu- 
mococcus,  streptococcus,  and  Staphylococcus  aureus  can  be  transmitted 
to  the  fetus.  Panas  ascribes  a  case  of  congenital  phthisis  bulbi  to 
variola  in  the  mother  (see  Leber  and  Addario).  Intra-uterine  in- 
fection by  gonococci  has  been  found  by  Parischeff  in  a  case  in  which 
the  membranes  ruptured  three  days  before  birth,  and  by  Nieden  in  a 
case  in  which  the  fetus  was  expelled  in  the  intact  membranes.  These 
cases  are  not  wholly  free  from  the  possibility  of  post-partum  infection. 
Purulent  conjunctivitis  is  by  no  means  always  caused  by  gonococci. 
In  forty-two  cases  Gonin  found  them  twenty-eight  times,  Koch-Weeks 


THE    CONJUNCTIVA  43 

bacillus  eight  times,  staphylococci  once,  streptococci  once.  This  agrees 
with  our  experience  at  Moorfields. 

Similarly  ophthalmia  neonatorum  can  only  in  part  be  referred  to 
the  gonococcus ;  it  is  absent  in  a  considerable  proportion  of  cases,  and 
other  organisms  are  found  (diplococci,  pneumococci,  streptococci, 
Bacterium  coli,  etc.).  Both  simple  catarrh  and  blennorrhcea  can  be 
caused  by  these  different  organisms  in  the  new-born  •  bad  blennorrhcea 
may  show  no  gonococci,  and  exceptionally  slight  catarrh  may  be  caused 
by  them  ;  gonococcic  blennorrhoea  has  a  severe  course  and  longer  dura- 
tion ;  ulcers  occur  both  in  the  blennorrhosic  and  in  the  slight  cases  ; 
gonococci  are  to  be  found  in  the  conjunctival  sac  for  days  and  even 
weeks  after  the  cessation  of  purulent  discharge — hence  the  need  of  pro- 
tracted treatment  (Groenouw).  In  a  great  number  of  cases,  especially 
of  slight  conjunctivitis  in  the  new-born,  no  specific  organisms  can  be 
found.  It  is  interesting  to  note  that  streptococci,  gonococci,  and 
Bacterium  coli  are  amongst  the  common  organisms  found  in  the  genital 
tracts  of  puerperal  women  (Menge  and  Kroenig).  These  authors  did 
not  find  pneumococci,  but  they  must  occasionally  be  present,  since  they 
are  sometimes  the  cause  of  puerperal  fever. 

The  Diplococcus  gonorrhcece  is  a  bun-shaped  diplococcus,  discovered 
by  Neisser  in  1879  (Fig-  I9)-  ^  is  readily  stained  by  methylene  blue, 
and  resembles  the  meningococcus  both  morphologically  and  in  the  fact 
that  it  is  decolourised  by  Gram's  method.  In  this  respect  both  differ 
from  the  pneumococcus.  Nothing  is  known  of  its  capacity  to  exist 
under  saprophytic  conditions,  but  it  is  almost  an  obligate  parasite,  and 
that,  too,  of  man  alone,  for  it  is  not  found  in  other  animals. 

Besides  its  characteristic  shape  and  its  decolorisation  by  Gram,  it 
is  peculiar  in  being  found  in  unusually  large  numbers  within  the  cyto- 
plasm of  polymorphonuclear  leucocytes.  Here  they  are  grouped  in 
pairs  or  heaps  around  the  nuclei  of  the  cells.  These  features  suffice  in 
all  cases  to  distinguish  the  gonococcus  from  staphylococci,  strepto- 
cocci, pneumococci,  and  most  other  micrococci  ;  and  this  is  fortunate, 
since  the  organism  is  cultivated  with  considerable  difficulty.  It  grows 
best  at  32° — 34°  upon  human  blood-serum,  or  a  mixture  of  agar  with 
ascitic  or  hydrocele  fluid  or  blood-serum,  or  a  mixture  of  human  blood- 
serum  and  bouillon.  The  addition  of  human  proteids  improves  the 
media  enormously,  but  it  can  be  got  to  grow  upon  ordinary  serum- 
agar.  The  addition  of  human  urine  also  seems  advantageous.  The 
cultures  usually  die  quickly,  and  in  the  case  of  the  conjunctiva  they 
are  rapidly  overwhelmed  by  other  organisms,  so  that  there  is  extreme 
difficulty  in  obtaining  a  pure  culture. 

Wilbrand,  Saenger  and  Staehlin  first  drew  attention  to  the  im- 
portance of  details  in  the  diagnosis  of  the  gonococcus  in  the  con- 
junctiva, and  their  results  were  confirmed  by  Neisser.  One  cover- 
glass  should  first  be  stained  by  a  simple  aniline  dye,  e.  g.  Loffler's 
methylene  blue,  and  then  another  by  Gram's  method,  if  diplococci  are 
found.  A  convenient  method  of  staining  is  Unna's,  with  a  mixture  of 
methyl  green  and  pyronin;1  the  gonococci  are  stained  red.  It  was 

1  Methyl  green  0^15  gm.,  pyronin  0*25  gm.,  alcohol  2'5  c.c.,  glycerin  2O  c.c.,  2  per 
cent,  carbolic  acid  to  looc.c. 


44  THE    PATHOLOGY   OF   THE    EYE 

formerly  considered  final  if  decolorisation  occurred  with  Gram,  but 
Krukenberg  found  a  diplococcus  giving  the  same  reactions  in  a  case  of 
slight  catarrhal  conjunctivitis.  It  was  probably  a  meningococcus.  It 
was  distinguished  from  the  gonococcus  by  the  ease  of  cultivation  on 
ordinary  ox-serum,  and  its  greater  resistance  to  variations  of  tempera- 
ture. The  rarity  of  this  organism  scarcely  vitiates  the  ordinary  rules  of 
procedure,  but  in  cases  of  doubt  cultivation  experiments  must  be  re- 
sorted to.  Frankel  also  found  the  Meningococcus  intracellularis  in 
three  children.  It  did  not  decolourise  so  readily  or  so  completely  by 
Gram. 

Pure  cultures  of  the  gonococcus  or  of  blennorrhceal  pus  produce  a 
purulent  discharge  when  inserted  in  the  rabbit's  conjunctival  sac 
(Groenouw). 

There  is  evidence  to  show  that  the  toxins  of  the  gonococcus  pro- 
duce purulent  conjunctivitis  both  in  men  and  rabbits  (Morax  and 
Elmassian). 

HALTENHOFF.— A.  f.  A.,  xiv,  1885.  GRIFFITH. — T.  O.  S.,  xx,  1900.  CHEATHAM. — 
A.  of  O.,  xxv,  1896.  LAWFORD. — Brit.  Med.  Jl.,  1901.  BYERS. — Montreal  Med.  Jl.,  1902. 
NEUBURGER. — K.  M.  f.  A.,  xli,  1903.  MORAX. — These  de  Paris,  1894.  LOEB. — Deutsch. 
Arch.  f.  klin.  Med.,  xxxii,  1886.  KOENIG. — Berl.  klin.  Woch.,  1897.  NEISSER  AND  BUMM. 
— Wien.  klin.  Woch.,  1897.  GIELEN. — Inaug.  Diss.  Bonn.,  1897.  DEUTSCHMANN. — A.  f. 
O.,  xxxvi,  i,  1890.  CLEMENT  LUCAS. — Trans.  R.  Med.-Chir.  Soc.,  Ixxxii.  ALTLAND. — K. 
M.  f.  A.,  xl,  1902.  E.  v.  HIPPEL. — A.  f.  O.,  xlvii,  1899.  LEBER  AND  ADDARIO. — A.  f.  O., 
xlviii,  i,  1899.  PARISCHEFF. — Nagel's  Jahresbericht,  1892.  NIEDEN. — K.  M.  f.  A.,  xxix, 
1891.  GONIN. — Rev.  med.  de  la  Suisse  Romande,  1899.  *GROENOUW. — A.  f.  O.,  Hi,  i, 
1901.  EPERON.— Les  Affections  blennorrhagiques  de  1'CEil,  Lausanne,  1902.  MENGE  AND 
KROENIG.  —  Bakteriologie  des  weiblichen  Genitalkanals,  Leipzig,  1897.  WILBRAND, 
SAENGER,  AND  STAEHLIN.— Jahresb.  d.  Hamburger  Staatskrankenanstalten,  iii,  1891-2. 
KRUKENBERG. — K.  M.  f.  A.,  xxxvii,  1899;  xxxviii,  1900;  xxxix,  1901.  ABELSDORFF  AND 
NEUMANN. — A.  f.  A.,  xlii.  1900.  URBAHN. — A.  f.  A.,  xliv,  Erganzungsheft,  1901.  WILDHOLZ. 
— A.  f.  Derm.,  1902.  KAYSER. — K.  M.  f.  A.,  xli,  Beilageheft,  1903.  FRANKEL. — Z.  f. 
Hygiene  u.  Infectionskrankheiten,  xxxi,  2,  1899.  HAGLUND. — K.  M.  f.  A.,  xxxviii,  Beilage- 
heft, 1900.  MORAX  AND  ELMASSIAN. — Ann.  d'Oc.,  cxxi,  1899;  Verhandl.  d.  internat.  Ophth. 
Kongr.,  Utrecht,  1899.  DAHLSTRONN,  K.  M.  f.  A.,  xli,  1903,  Beilageheft. 

THE  KOCH-WEEKS  BACILLUS 

The  commonest  cause  of  acute  contagious  conjunctivitis  seems  to 
be  the  Koch-Weeks  bacillus.  It  was  discovered  by  Koch  in  Egypt  in 
1884,  and  was  wrongly  regarded  by  him  as  a  concomitant  of  Egyptian 
ophthalmia.  It  was  rediscovered  by  Weeks  in  New  York  in  1885,  and 
proved  by  him  to  be  the  cause  of  an  acute  contagious  conjunctivitis, 
which  had  no  relationship  with  trachoma.  Kartulis  found  it  again  in 
Egypt  in  1887,  and  Wilbrand,  Saenger  and  Staehlin  in  Hamburg 
in  1891.  Since  then  it  has  been  discovered  almost  everywhere — Morax 
(1894)  in  Paris,  Juler  (1894)  in  England,  Gasparrini  (1896)  in  Italy, 
etc., — so  that  failure  to  find  it  in  certain  places  by  Gifford,  Axenfeld, 
Fuchs,  etc.,  is  probably  due  to  chance.  It  has  been  most  thoroughly 
and  most  successfully  investigated  by  Morax. 

The  bacillus  mostly  attacks  young  people— up  to  twenty  years  old, 
— but  it  occurs  at  all  ages.  It  causes  an  acute  muco-purulent  con- 
junctivitis ;  no  follicles  are  formed,  but  it  frequently  attacks  the 
sufferers  from  phlyctenular  conjunctivitis.  The  cornea  is  rarely 
affected,  and  then  only  by  small  grey  superficial  infiltrates ;  central 


THE    CONJUNCTIVA  45 

perforation  has  been  described  once  (Morax  and  Petit).  The  pre- 
auricular  glands  are  sometimes  enlarged.  It  has  been  found  in  the 
new-born  (Panas,  Coppez)  ;  Coppez'  case  was  pseudo- membranous. 

The  bacilli  are  best  stained  by  fixing  the  film  with  sublimate,  and 
subsequently  washing  out  (less  well  by  heat),  and  then  treating  with  a 
carbolised  solution  of  methylene  blue  or  methyl  violet.  They  are 
found  lying  between  the  leucocytes,  and  also  within  the  protoplasm. 
They  very  nearly  resemble  the  bacilli  of  mouse-septicaemia,  but  are 
thinner.  They  appear  as  very  short  fine  rods  (o'8 — 2ju),  staining  less 
deeply  than  the  nuclei  of  the  cells  (Fig.  20).  They  are  often  found 
lying  end  to  end,  so  as  to  form  chains  of  two  or  three  links,  or  side  by 
side.  The  ends  are  rounded,  and  often  show  a  deeper  polar  staining. 
The  number  varies  greatly  according  to  the  period  and  intensity  of  the 


FIG.  20. — KOCH-WEEKS  BACILLI,      x   IQOO. 
Photograph  by  Henderson.     Film  from  conjunctival  sac. 

infection.  They  are  often  found  in  almost  pure  culture,  but  not  infre- 
quently diplococci  are  also  present.  In  these  cases  it  is  not  uncommon 
to  find  follicles  in  the  conjunctiva  (Wilbrand,  Saenger,  and  Staehlin). 
They  are  decolourised  by  Gram's  method.  These  characteristics 
render  diagnosis  by  films  easy. 

Cultures  are  difficult,  but  a  nearly  allied  form  grows  more  easily 
(v.  infra,  Weichselbaum  and  Miiller).  The  bacillus  rarely  grows  on 
gelatine  or  serum,  occasionally  on  agar  (after  two  days),  best  on  0*5  per 
cent,  agar,  or  the  culture  media  most  suitable  for  gonococci.  It  is 
essential  that  the  agar  should  be  very  moist.  The  more  virulent  the 
conjunctivitis,  the  better  are  the  cultures.  Owing  to  the  consistency  of 
0*5  per  cent,  agar,  cultivation  is  best  carried  out  in  Petri  dishes.  After 
keeping  at  35°  Celsius,  very  fine,  scarcely  perceptible  granulations 
appear  on  the  surface  after  twenty-four  to  thirty-six  hours.  These 


46 

transparent  colonies  very  much  resemble  those  of  the  influenza  bacillus. 
Besides  these  there  are  larger,  greyish,  more  opaque  colonies.  These 
contain  bacilli  which  stain  with  Gram,  and  generally  show  club-shaped 
involution  forms.  The  club-shaped  bacilli  occur  in  other  forms  of  con- 
junctivitis (ophthalmia  neonatorum,  etc.).  They  are  easily  isolated 
from  the  pure  Koch-Weeks  bacilli,  but  it  is  difficult  to  obtain  the  latter 
without  the  former  (Greeff).  It  is  best  effected  by  inoculating  the 
condensed  water  in  a  tube,  and  then  making  a  second  and  third  similar 
inoculation,  finally  spreading  the  water  on  the  surface  of  the  medium. 
Morax  has  succeeded  in  obtaining  cultures  on  the  ordinary  media,  but 
this  usually  fails.  Subcultures  always  fail  after  the  fifth  day,  and  often 
before;  Morax  only  obtained  two  or  three  generations  on  0*5  per  cent, 
agar. 

The  bacilli  in  cultures  are  non-motile,  stain  faintly  with  aniline 
dyes,  and  are  decolourised  by  Gram.  They  cease  to  stain  after  a  few 
weeks.  They  occur  in  clumps,  and  are  mostly  short,  like  those  in  the 
conjunctiva;  but  others,  two  or  three  times  as  long,  occur. 

Weeks  failed  to  obtain  positive  results  by  inoculation  in  men  and 
animals.  Morax  failed  with  animals,  but  succeeded  with  men.  There 
is  an  incubation  period  of  two  to  three  days  ;  the  opposite  eye  usually 
becomes  infected  two  or  three  days  later.  The  inflammation  reaches 
its  height  at  about  the  sixth  or  seventh  day.  On  the  first  day,  only 
few  bacilli  can  be  found  ;  after  the  third  they  are  numerous  ;  cauterisa- 
tion with  silver  nitrate  (0*5  per  cent.)  on  the  sixth  day  led  to  great 
diminution  of  the  bacilli  on  the  ninth  day,  and  to  total  absence  on  the 
tenth  day. 

Microscopic  sections  of  the  conjunctiva,  removed  on  the  third  day, 
showed  ordinary  lymphocytic  infiltration,  vascular  congestion,  and 
dilatation  of  lymphatics.  The  epithelium  was  intact.  Sections  stained 
by  carbol-thionin  and  wrashed  out  with  absolute  alcohol  (Nicholle's 
method)  showed  groups  of  bacilli  in  the  superficial  layers  of  the  epithe- 
lium, and  deeper  amongst  the  leucocytes.  There  were  none  in  the 
deeper  tissues. 

It  is  doubtful  if  the  Koch-Weeks  bacillus  can  give  rise  to  a  chronic 
conjunctivitis,  but  the  investigations  of  Hoffmann,  and  of  Weichsel- 
baum  and  Muller  tend  to  show  that  it  can.  The  latter  authors  have 
obtained  rather  different  results  from  Morax,  chiefly  with  regard  to 
details  of  cultivation.  They  compare  the  bacillus  to  that  of  influenza, 
and  to  Miiller's  trachoma  bacillus  (v.  "Trachoma").  It  is  probable 
that  the  bacillus  found  by  them  is  only  a  modified  form  of  the  Koch- 
Weeks  bacillus. 

KOCH. — Wien.  med.  Woch.,  1883;  Arbeiten  a.  d.  kaiserl.  Gesundheitsamt,  iii,  4,  1884. 
WEEKS. — A.  of  O.,  xv,  1886.  KARTULIS. — Centralbl.  f.  Bakteriologie,  i,  No.  40,  1887. 
WILBRAND,  SAENGER,  AND  STAEHLIN. — Loc.  cit.,  1891-2,  1894.  MORAX. — These  de  Paris, 
1894.  JULER. — Brit.  Med.  Jl.,  1894.  STEPHENSON. — Epidemic  Ophthalmia,  London.  1896. 
GASPARRINI. — Ann.  di  Ott.,  xxv,  1896.  MORAX  AND  BEACH. — A.  of  O.,  xxv,  1896.  MORAX 
AND  PETIT. — Ann.  d'Oc.,  cxx,  1898.  MORAX  AND  ELMASSIAN. — Ann.  d'Oc.,  cxxi,  1899. 
PANAS. — Congres  d'Opht.  Paris,  1891.  ELMASSIAN. — Ann.  d'Oc.,  cxxii,  1900.  GREEFF. — 
In  Orth's  Lehrbuch.,  Berlin,  1902.  RYMOWITSCH. — Wratsch,  xx,  1900-1.  MARKUS. — 
Munch,  med.  Woch.,  1901.  HOFFMANN.- — Z.  f.  Hygiene  und  Infectionskrankheiten,  xxxiii, 
1900.  KAMEN. — C.  f.  Bakt.,  xxv,  1899.  WEICHSELBAUM  AND  MULLER. — A.  f.  O.,  xlvii,  i, 
1898.  MULLER. — A.  f.  A.,  xl,  1899;  A.  f.  O.,  Ivii,  i,  1903. 


THE    CONJUNCTIVA 


47 


THE    MORAX-AXENFELD    DlPLOBACILLUS 

The  diplobacillus  discovered  independently  in  1896  by  Morax  and 
Axenfeld  is  the  cause  of  one  of  the  commonest  forms  of  catarrhal 
conjunctivitis.  It  occurs  at  all  ages,  but  especially  in  adults.  It  is 
characterised  by  a  chronic,  not  very  severe  blepharo-conjunctivitis, 
without  follicles  or  membrane,  but  with  a  typical  erythema  of  the  edges 
of  the  lids,  with  slight  maceration  of  the  skin,  most  marked  at  the 
angles,  especially  the  inner  angle  (angular  conjunctivitis).  The  secretion 
is  watery  and  not  copious.  Superficial  infiltration  of  the  cornea  is  not 
uncommon  (Peters),  and  this  also  contains  the  organism  (Morax  and 


FIG.  21. — DIPLOBACILLI  (Morax-Axenfeld).      x    1000. 
Photograph  by  Henderson.     Film  from  conjunctival  sac. 

Petit,  Petit  [i]).  The  conjunctivitis  is  rapidly  cured  by  zinc  sulphate 
lotion,  but  shows  no  tendency  to  spontaneous  cure. 

The  diplobacillus  is  apparently  found  in  all  countries,  and  is 
extremely  contagious.  Eyre  found  it  in  2.\  per  cent,  of  all  the  patients 
in  Guy's  Hospital  eye  clinic,  and  it  is  equally  prevalent  elsewhere. 
Biard  found  it  simultaneously  in  the  nose.  In  310  cases  of  catarrhal 
conjunctivitis  Gonin  found  the  diplobacilli  185  times,  Koch- Weeks 
bacilli  10  times,  pneumococci  10  times,  streptococci  5  times,  Staph. 
aureus  83  times. 

Cover-glass  preparations  are  quite  characteristic  (Fig.  21).  The 
bacilli  are  generally  very  numerous  ;  they  are  large  (2  /j.  by  I  ^t,  but  this 
varies  considerably),  generally  occur  in  pairs,  and  often  in  chains. 
They  are  decolourised  by  Gram's  method.  They  do  not  possess  a  well- 
defined  capsule,  but  this  is  sometimes  present  (Gifford,  Hoffman,  zur 


48  THE    PATHOLOGY   OF   THE    EYE 

Nedden).  A  fine  capsule  can  be  demonstrated  ordinarily  by  special 
capsule  staining  (Bietti). 

Cultures  are  obtained  with  some  difficulty,  and  only  on  blood- 
serum,  serum-agar,  or  the  usual  media  for  gonococci.  Blood-serum  is 
liquefied.  Cultures  on  serum-agar  form  minute  transparent  spots,  not 
unlike  pneumococcus  cultures.  The  agar  is  not  liquefied.  The  diplo- 
bacilli  grow  best  on  alkaline  media,  and  are  obligate  aerobes  ;  they  are 
non-motile. 

The  diplobacillus  of  Morax  is  not  pathogenic  for  animals,  but  is 
readily  transferred  from  pure  cultures  to  the  human  conjunctiva,  the 
incubation  period  being  about  four  days. 

Allied  to  the  Morax-Axenfeld  bacillus  is  the  Bacillus  liquefaciens  (Petit 
[2]).  It  is  a  diplobacillus,  i  /m — 17,11  by  0*8  /u — i  n,  the  diplo-form 


FIG.  22. — DIPLOBACILLI  (Morax-Axenfeld).      x    1000. 

Photograph    by   Henderson.       Culture,   by   Eyre,  on   serum-agar,  eight  days, 
showing  involution  forms. 

being  constant.  It  occurs  in  some  superficial  ulcers  of  the  cornea, 
accompanied  by  slight  iritis  and  hypopyon  (McNab).  McNab  found 
capsules,  which  were  not  seen  by  Petit.  It  gives  a  negative  reaction 
with  Gram.  It  grows  on  all  ordinary  media,  has  a  low  power  of 
resistance  to  heat,  but  considerable  to  dryness.  It  liquefies  gelatin  in 
stab  cultures  at  15° — 20°  C.,  but  on  cultivation  this  power  appears  to  be 
lost  (McNab).  It  rapidly  liquefies  blood-serum,  in  this  respect 
differing  from  Friedlander's  and  zur  Nedden's  bacilli  (q.  v.).  It  differs 
from  the  Morax-Axenfeld  bacillus  in  growing  readily  on  pure  agar. 

MORAX. — Ann.  de  1'Institut  Pasteur,  juin,  1896;  Ann.  d'Oc.,  cxvii,  1897.  AXENFELD. — 
B.  d.  o.  G.,  1896;  Centralbl.  f.  Bakteriologie,  xxi,  1897;  Berl.  klin.  Woch.,  1897.  PETERS. 
— K.  M.  f.  A.,  xxxv,  1897.  BIARD. — These  de  Paris,  1897.  GONIN. — Rev.  med.  de  la 
Suisse  Romande,  1899.  BACH  AND  NEUMANN. — A.  f.  A.,  xxxvii,  1898.  MORAX  AND  PETIT. 
— Ann.  d'Oc.,  cxx,  1898.  PETIT  (i). — These  de  Paris,  1900.  EYRE. — Brit.  Med.  Jl., 


THE    CONJUNCTIVA  49 

GIFFORD. — Annals  of  Ophth.,  vii,  1898.  HOFFMANN. — A.  f.  O.,  xlviii,  3,  189^.  LOBANOW. 
— A.  f.  O.,  li,  3,  1900.  ZUR  NEDDEN. — K.  M.  f.  A.,  xxxix,  1901.  PFLUGER. — Korre- 
spondenzbl.  f.  Schweizer  Aerzte,  1902.  BIETTI. — Ann.  di  Ott.,  xxviii,  2,  1899.  PETIT  (2). — 
Ann.  d'Oc.,  cxxi,  1899  ;  Recherches  clin.  et  bacteriol.  sur  les  Infections  aigues  de  la  Cornee, 
1900.  McNAB  (working  under  Axenfeld). — Personal  communication  ;  K.  M.  f.  A.,  xlii,  1904. 

THE  DIPHTHERIA  BACILLUS  (KLEBS-LOFFLER) 

Membranous  conjunctivitis  was  mentioned  by  Mackenzie  in  1845, 
and  possibly  still  earlier  by  Wharton  Jones.  It  was  not,  however,  until 
1854  tnat  von  Graefe  gave  a  satisfactory  description  of  the  severer  type. 
It  is  a  mistake  to  ascribe  the  account  of  the  milder  or  croupous  form  to 
the  earlier  writers  Bouisson  and  Chassaignac  (1846)  (Coppez  [i]). 


FIG.  23. — DIPHTHERIA  BACILLI,      x   1000. 
Photograph  by  Henderson.     Culture,  by  Eyre,  on  blood-serum,  eighteen  hours. 

Babes,  in  1886,  first  discovered  the  Klebs-Loffler  bacillus  in  the  con- 
junctiva. 

The  type  of  conjunctivitis  caused  by  the  diphtheria  bacillus  varies 
much ;  it  is  almost  always  membranous,  but  both  its  local  severity  and 
the  severity  of  the  general  symptoms  differ  enormously.  This  is 
acknowledged  by  an  overwhelming  consensus  of  opinion.  On  the  other 
hand,  there  is  an  equally  wide  agreement  that  membranous  con- 
junctivitis (q.  v.)  is  caused  by  many  other  agents,  both  chemical  and 
bacteriological.  In  thirteen  cases  of  membranous  conjunctivitis  Gonin 
found  the  Klebs-Loffler  bacillus  seven  times,  staphylococci  four  times, 
pneumococci  once,  and  Koch- Weeks  bacillus  once.  In  most  cases  of 
true  diphtheria,  other  organisms,  especially  staphylococci  and  strepto- 
cocci, are  found  besides  the  Klebs-Loffler  bacillus,  and  probably  the 
nature  of  the  mixed  infection,  combined  with  variability  in  the  reaction 

4 


50  THE    PATHOLOGY    OF   THE    EYE 

of  the  patient's  tissues,  determines  whether  the  membrane  will  be 
merely  superficial  and  benign,  or  deeply  necrosing  and  malignant.  It 
may  even  be  absent ;  such  cases  are  described  in  diphtheria  epidemics, 
and  in  cases  of  membranous  conjunctivitis  in  the  other  eye  (Sourdille, 
Uhthoff,  Aubineau,  v.  Hippel,  Pichler,  Copper).  The  idea  that  the 
longer  forms  of  the  bacillus  are  most  virulent  (Martin)  cannot  be 
substantiated  (Sourdille,  Morax,  etc.)-  There  can  be  no  doubt  that 
the  condition  of  the  tissues  is  of  great  importance — that  the  diphtheria 
bacillus,  in  fact,  is  only  conditionally  contagious  for  the  conjunctiva. 
This  is  seen  clearly  in  rabbits,  in  which  inoculation  into  the  normal 
conjunctival  sac  fails  if  the  epithelium  is  uninjured.  Uhthoff,  indeed, 
considers  previous  conjunctivitis  essential  in  human  beings,  and 
eczema  of  the  lids  is  common  in  the  croupous  form  (Schmidt-Rimpler). 
The  probability  of  Uhthoff  s  view  is  supported  by  Axenfeld,  who  points 
out  that  virulent  diphtheria  bacilli  have  been  found  on  the  normal 
mucous  membrane  of  the  throat.  They  have  also  been  found  in  the 
conjunctiva  (Coppez,  Pichler).  The  bacilli  persist  for  a  long  time 
during  convalescence,  and  remain  virulent  (Sourdille,  Uhthoff,  Schirmer) ; 
repeated  attacks  may  occur,  probably  owing  to  the  passing  off  of  a 
temporary  immunity  conferred  by  the  previous  attack.  There  is  a  rare 
chronic  recurring  form  (Valude,  Arlt,  Coppez,  Morton),  which  is  only 
occasionally  due  to  the  Klebs-Loffler  bacillus  ;  staphylococci  have  been 
found,  but  the  bacteriology  has  not  been  well  worked  out  (see  "  Mem- 
branous Conjunctivitis"). 

Mixed  infection,  e.g.  with  streptococci,  does  not  necessarily  cause  a 
severe  type  (Sourdille),  but  the  majority  of  cases  are  worse  than  with 
pure  diphtheria.  Uhthoff  almost  invariably  found  staphylococci  and 
streptococci,  though  the  course  of  the  disease  was  usually  mild  and 
uncomplicated. 

There  is  now  ample  evidence  to  show  that  antitoxin  treatment  is 
very  effectual  in  true  diphtherial  conjunctivitis  (e.g.  Jessop,  Stephenson). 
Many,  however,  agree  that  it  fails  to  produce  amelioration  of  corneal 
inflammation,  when  that  has  supervened  (Gonin,  Uhthoff,  Coppez  [2], 
Wagner,  Axenfeld).  It  has  naturally  been  found  to  be  less  effectual 
in  severe  mixed  infections  (e.g.  with  gonococcus,  Wagner).  Morax 
and  Elmassian  have  shown  that  membranous  conjunctivitis  can  be  pro- 
duced in  rabbits  by  dropping  in  diphtheria  toxins,  even  without  previous 
injury  to  the  conjunctiva;  the  cornea  is  also  affected  (Coppez  [3]). 
There  is  a  definite  latent  period  of  twenty-four  to  twenty-eight  hours. 
These  results  lend  reason  to  the  suggestion  that  the  antitoxin  serum 
should  also  be  applied  locally  (Coppez  [4],  Mongour). 

Randolph  has  found  that  continued  instillations  of  the  toxins  of  the 
B.  diphtheria  and  of  other  organisms  (gonococcus,  streptococcus, 
Staphylococcus  aureus,  and  B.  xerosis),  produced  by  filtration  of  sugar-free 
bouillon  cultures  of  varying  ages,  produced  no  reaction  on  the  normal 
conjunctivas  of  rabbits.  If,  on  the  other  hand,  small  amounts  of  the 
filtrates  from  even  most  recent  cultures  were  injected  into  the  tissue  of 
the  conjunctiva,  marked  inflammatory  reaction  followed.  This  tends  to 
show  that  the  bacteria  are  dependent  in  their  action  upon  some  lesion 
of  the  conjunctiva. 


THE    CONJUNCTIVA  51 

The  subject  is  made  more  complex  by  the  universal  presence  of  the 
xerosis  bacillus.  The  relationship  of  the  two  organisms  will  be  dis- 
cussed later. 

The  diphtheria  bacillus  was  discovered  by  Klebs  in  1875,  but  was 
only  fully  investigated,  and  proved  to  be  pathogenic,  by  Loffler  in  1884. 
It  stains  well  with  methylene  blue,  and  is  not  decolourised  by  Gram's 
method.  It  is  not  quite  so  long  as  the  tubercle  bacillus,  and  rather 
thicker ;  but  it  occurs  in  very  variable  forms,  straight  or  curved  (Fig. 
23).  The  extremities,  which  are  more  deeply  stained,  are  often 
slightly  enlarged  ;  and  this  condition  is  often  exaggerated  by  the  forma- 
tion of  small,  very  deeply  staining  bodies  at  the  poles,  resembling 
spores.  The  bacillus,  however,  does  not  form  spores. 

It  grows  best  upon  Loffler's  blood-serum,1  but  also  well  upon  serum- 
agar,  alkaline  bouillon,  etc.  On  solid  media  at  temperatures  from 
20 — 42°  C.,  it  forms  flat,  greyish  colonies  in  twenty-four  hours.  Involu- 
tion forms  are  common  in  cultures,  the  bacilli  appearing  cut  up  into 
small  rounded  masses,  some  of  which  have  a  smaller  diameter  than  the 
bacillus,  others  being  larger  and  oval  in  shape.  On  glycerine  agar  the 
rods  are  shorter  and  thicker  than  usual.  Both  morphologically  and 
physiologically — production  of  acid,  indol  formation,  etc. — the  bacilli 
vary  greatly,  and  this  fact  probably  accounts  for  many  of  the  so-called 
pseudo-diphtheria  bacilli.  Special  staining  reactions,  such  as  Roux' 
and  Neisser's  (v.  infra),  are  by  no  means  specific. 

Subcutaneous  inoculation  of  guinea-pigs  with  bouillon  culture  kills 
within  thirty-six  hours.  A  small  patch  of  grey  membrane  is  formed  at 
the  site  of  inoculation,  with  inflammatory  redema  and  haemorrhages 
around. 

COPPEZ  (i). — Des  Conjonctivites  pseudomembraneuses,  Bruxelles,  1897.  BABES. — 
Prag.  Med.,  1886.  GONIN. — Rev.  med.  de  la  Suisse  Romande,  1899.  UHTHOFF. — Comptes 
rendus  du  XII  Congres  internat.  de  Me'd.,  Moskau,  1898;  Vossius'  Sammlung,  ii,  5,  1898. 
SCHIRMER. — A.  f.  O.,  xi,  5,  1894.  MORTON. — T.  O.  S.,  xiii,  1893.  PICHLER. — B.  z.  A.,  xxiv, 
1896.  JESSOP. — T.  O.  S.,  xxii,  1902.  STEPHENSON. — T.  O.  S.,  xxii,  1902.  WAGNER. — 
Inaug.  Diss.,  Giessen,  1898.  AXENFELD. — Munch,  klin.  Woch.,  1898.  COPPEZ  (2). — A. 
d'O.,  xix,  1899.  MORAX  AND  ELMASSIAN. — Ann.  d'Oc.,  cxxi,  1899;  Verhandl.  d.  IX  internat. 
Kongr.,  Utrecht,  1899.  COPPEZ  (3). — Verhandl.  d.  internat.  Kongr.,  Utrecht,  1899;  Z.  f.  A., 
ii,  1899,  Beilageheft.  COPPEZ  (4). — Rev.  gen.  d'O.,  1897.  MONGOUR. — Ann.  d'Oc.,  cxx, 
1898.  SOURDILLE. — Rev.  mens.  des  Maladies  de  1'Enfance,  1895;  A.  d'O.,  xiv,  1894. 
RANDOLPH. — Bull,  of  the  Johns  Hopkins  Hospital,  xiv,  1903.  BIETTI. — K.  M.  f.  A.,  xli, 
1903,  Beilageheft. 

THE  XEROSIS  BACILLUS  (KUSCHBERT — NEISSER) 

The  so-called  xerosis  bacillus  much  resembles  the  diphtheria  bacillus. 
It  occurs  extremely  frequently  in  the  normal  conjunctiva,  and  in  great 
numbers  in  xerosis ;  it  is  not,  however,  the  cause  of  this  complaint,  but 
the  conditions  then  present  are  very  favourable  for  its  development. 

The  bacillus  was  discovered  by  Kuschbert  and  Neisser  in  1883  in 
twenty-five  cases  of  xerosis  in  an  orphanage  at  Breslau.  It  was  dis- 
covered independently  by  Leber  in  the  same  year,  and  this  discovery 
was  confirmed  by  Schulz.  Weeks,  in  1887,  failed  to  inoculate  rabbits' 

1  Three  parts  calf's  or  lamb's  blood-serum,  with  i  part  of  peptone-bouillon  made  from 
veal  and  containing  i  per  cent,  grape  sugar. 


52  THE    PATHOLOGY    OF   THE    EYE 

conjunctive  from  xerosis.  Frankel  and  Franke,  in  the  same  year, 
failed  to  transfer  the  disease  from  children  to  animals  and  children, 
but  regarded  the  bacillus  as  the  cause. 

The  xerosis  bacillus  is  identical  morphologically  with  the  diphtheria 
and  pseudo-diphtheria  bacilli ;  it  is  stained  by  ordinary  aniline  dyes 
and  grows  on  the  same  culture  media,  forming  similar  colonies.  It 
differs  from  the  diphtheria  bacillus  in  not  producing  an  acid  reaction 
in  neutral  peptone-bouillon  (Eyre),  and,  as  we  have  seen,  it  is  not 
pathogenic  for  men  or  animals.  Frankel  regarded  it  as  a  non-virulent 
diphtheria  bacillus,  similar  to  those  found  in  the  throat  by  Roux  and 
Yersin,  which  became  virulent  when  mixed  with  streptococci ;  they 
failed  to  make  this  bacillus  virulent  by  any  method,  but  this  result  was 
also  obtained  in  the  case  of  very  attenuated  diphtheria  bacilli.  The 
failure  to  produce  acid,  described  by  Eyre,  is  only  a  question  of  degree, 
as  the  xerosis  bacillus  produces  a  small  amount  in  time  (Axenfeld). 
Like  diphtheria,  the  bacillus  varies  in  rapidity  of  growth  and  in  form 
on  various  culture  media ;  and,  indeed,  different  forms  occur  in  the  con- 
junctiva. One  of  the  most  important  of  these,  described  by  Gelpke  as 
the  cause  of  an  epidemic  acute  catarrhal  conjunctivitis  and  named  the 
Bacillus  septatus,  has  been  the  subject  of  much  dispute  (Heinersdorff  [i]  , 
Axenfeld).  Gelpke's  results  were  founded  upon  1559  patients ;  the 
catarrh  showed  typical  swelling  of  the  fornix  as  compared  with 
relatively  slight  chemosis  of  the  ocular  conjunctiva  ("  Schwellungs- 
katarrh  ").  A  pseudo-membrane  was  rapidly  formed,  and  corneal  ulcers 
and  iritis  were  common.  The  Bacillus  septatus  was  found  in  all  cases  ; 
morphologically  and  culturally  the  differences  from  the  xerosis  bacillus 
are  minimal.  Gelpke  relies  upon  the  fact  that  he  has  succeeded  in 
transferring  the  infection  to  human  conjunctivae.  He  regards  the 
catarrh  as  an  attenuated  diphtheria.  Gelpke  cannot  be  considered  to 
have  proved  the  identity  of  his  organism. 

Neisser,  in  1897,  described  a  method  of  staining  which  he  thought 
definitely  distinguished  the  xerosis  from  the  diphtheria  bacillus. 
Cultures  are  made  upon  Loffler's  blood-serum  at  35°  ;  cover-glass  pre- 
parations are  made  after  ten  to  twenty-two  hours'  incubation ;  these 
are  stained  for  one  to  three  seconds  with  acetic  acid  methylene  blue,  and 
then  for  three  to  five  seconds  with  Bismarck  brown.  True  diphtheria 
bacilli  are  stained  brown,  and  the  polar  globules  described  by  Ernst 
are  stained  blue.  The  latter  are  not  stained  in  xerosis  bacilli.  The 
difference  is  only  one  of  time  (Schanz),  for  xerosis  bacilli  react  in  the 
same  manner  after  forty-six  to  forty-eight  hours  (Dotsch).  Heiners- 
dorff (2)  investigated  xerosis  bacilli  from  sixty  normal  conjunctivae, 
and  never  obtained  the  polar  stain  within  twenty  to  twenty-four  hours' 
cultivation.  Frankel  considered  that  a  negative  result  eliminated  true 
diphtheria,  though  the  converse  did  not  hold  good ;  he  obtained  a 
positive  result  once  with  a  pseudo-diphtheria  culture,  and  three 
times  with  a  positive  result  the  organism  was  not  pathogenic  for 
guinea-pigs.  Loffler,  however,  at  the  International  Congress  for 
Hygiene  in  Madrid  stated  that  the  reaction  sometimes  failed  with 
true  diphtheria  bacilli,  and  this  has  been  confirmed.  Staining  of 
a  few  globules  may  be  neglected;  the  characteristic  polar  staining  must 


THE    CONJUNCTIVA  53 

be  general.  The  positive  reaction  certainly  seems  to  be  very  rare 
with  xerosis  bacilli,  and  it  is  so  far  useful  as  indicating  treatment  by 
antitoxin  whenever  it  is  found. 

The  resemblance  between  the  xerosis  and  the  diphtheria  bacillus 
has  led  some  to  regard  the  former  as  merely  a  non-virulent  type  or 
stage  of  the  latter,  whilst  others — and  those  the  majority — affirm  their 
independence.  Schanz,  who  has  paid  much  attention  to  the  subject, 
objects  to  the  term  "  pseudo-diphtheria"  bacillus,  and  prefers  to  call  it 
the  non-virulent  (ungiftig)  Loffler  bacillus.  Practically  all  authors 
agree  that  the  two  cannot  always  be  distinguished  morphologically 
(Schanz,  Heinersdorff,  Axenfeld,  Uhthoff,  Pes,  etc.).  Similarly  they 
are  indistinguishable  by  culture,  though  the  question  of  acid  formation 
before  referred  to  must  be  remembered,  and  the  fact  that  the  true 
diphtheria  bacillus  usually  grows  better  on  blood-serum,  and  more 
diffusely  in  bouillon.  The  universality  of  various  pseudo-diphtheria 
bacilli  must  also  be  borne  in  mind.  Hala  has  recently  re-investigated 
the  subject,  and  sums  up  in  favour  of  the  fundamental  identity  of 
diphtheria,  pseudo-diphtheria,  and  xerosis  bacilli  ("  coryna  "  or  club- 
shaped  bacilli). 

The  essential  point  is  undoubtedly  the  question  of  virulence,  and 
almost  all  authors  agree  with  Schanz  that  virulent  diphtheria  bacilli 
are  not  infrequently  found  in  slight  cases  of  membranous  conjuncti- 
vitis, whilst  often  only  the  non-virulent  forms  are  found  in  severe  cases. 
Any  list  of  carefully  investigated  consecutive  cases  of  membranous  con- 
junctivitis will  show  this  (e.  g.  Jessop,  Stephenson,  Pichler)  ;  few, 
however,  will  have  the  temerity  to  think  that  the  Klebs-Loffler  bacillus 
was  present  in  all  the  cases,  but  overlooked  in  some  (Stephenson). 

Organisms  belonging  to  the  group  of  pseudo-diphtheria  bacilli  have 
been  found  by  Leber  and  Addario  in  a  case  of  congenital  panophthal- 
mitis  in  a  goat. 

KUSCHBERT  AND  NfiissER. — Bresl.  arztl.  Z.,  1883.  LEBER. — A.  f.  O.,  xxix,  i,  1883. 
SCHULZ. — A.  f.  O.,  xxx,  4,  1884.  WEEKS. — A.  f.  A.,  xvii,  1887.  FRANKEL  AND  FRANKE. — 
A.  f.  A.,  xvii,  1887.  EYRE. — Lancet,  Dec.,  1895;  Jl.  of  Path,  and  Bac.,  1896.  GELPKE. — 
Bacillus  septatus,  Karlsruhe,  1898.  AXENFELD. — In  Lubarsch  and  Ostertag,  1901.  NEISSER. 
— Z.  f.  Hygiene,  xxiv,  1897.  DOTSCH. — A.  f.  O.,  xlix,  2,  1900.  HEINERSDORFF. — -Centralbl. 
f.  Bakt,  xxiii,  1898;  A.  f.  O.,  xlvi,  i,  1898.  FRANKEL. — Munch,  med.  Woch.,  1898.  SCHANZ. 
— Berl.  klin.  Woch.,  1896,  1897,  1898;  B.  d.  o.  G.,  1898;  Deutsch.  med.  Woch.,  1899; 
Z.  f.  Hygiene,  xxxii,  1899.  BIETTI. — Ann.  di  Ott.,  xxvii,  1898  ;  K.  M.  f.  A.,  xli,  Beilageheft, 
1903.  PES. — Ann.  di  Ott.,  xxviii,  1898.  HALA. — Z.  f.  A.,  ix,  1903.  JESSOP. — T.  O.  S., 
xxii,  1902.  STEPHENSON. — T.  O.  S.,  xxii,  1902.  PICHLER. — B.  z.  A.,  xxiv,  1898.  LEBER 
AND  ADDARIO. — A.  f.  O.,  xlviii,  i,  1899. 

OTHER  MICRO-ORGANISMS 

Other  micro-organisms  which  have  from  time  to  time  been  found  in 
the  normal  or  diseased  conjunctival  sac  are  almost  innumerable  (see 
McFarland  and  Kneass).  In  many  cases  they  are  ordinary  saprophytes, 
in  others  the  results  have  never  been  confirmed.  A  few  require  passing 
mention. 

MCFARLAND  AND  KNEASS. — In  Norris  and  Oliver,  System,  ii,  1897. 
Bacillus    coli    communis. — It    was    only   to   be   expected   that  this 
organism  \vould  be  found  in  the  conjunctiva.    The  credit  of  discovering 


54  THE    PATHOLOGY    OF   THE   EYE 

it  there  rests  with  Randolph,  who  found  it  in  the  pus  from  a  case  of 
traumatic  panophthalmitis.  It  has  been  found  since  in  ophthalmia 
neonatorum  by  Axenfeld,  Cramer,  Bietti,  Groenouw,  in  pseudo-mem- 
branous conjunctivitis  by  Tailor,  etc.  zur  Nedden  proved  it  to  be  the 
cause  of  a  case  of  hypopyon  keratitis. 

RANDOLPH. — Am.  ]I.  of  Med.  Sc.,  1893.  AXENFELD. — Korrespondenzbl.  der  Mecklenb. 
Aerztevereins,  1898.  CRAMER. — Arch.  f.  Gynakol.,  lix.  BIETTI. — K.  M.  f.  A.,  xxxvii,  1899. 
GROENOUW. — A.  f.  O.,  Hi,  i,  1901.  TAILOR. — Lav.  d.  clin.  oc.  di  Napoli,  iv,  1896.  ZUR 
NEDDEN. — K.  M.  f.  A.,  xl,  1902. 

Bacillus  influenzas  (Pfeiffer). —  Cases  of  conjunctivitis  due  to  the 
pseudo-influenza  bacillus  have  been  recorded  by  zur  Nedden.  It  cannot 
be  distinguished  morphologically  in  smears  from  the  Koch- Weeks 
bacillus  (q.  v.). 

ZUR  NEDDEN. — K.  M.  f.  A.,  xxxviii,  1900;  xli,  1903.  JUNDELL. — Mittheil.  aus  d. 
Augenklinik,  iii,  Stockholm,  1902. 

Bacillus  pneumonias  (Friedlander)  was  found  in  a  case  of  pseudo- 
membranous  conjunctivitis  by  Eyre,  and  has  since  been  found  rarely 
by  Groenouw.  v.  Ammon  obtained  it  occasionally  in  the  conjunctival 
sac  of  new-born  infants.  It  is  probably  identical  with  the  ozsena. 
bacillus  (Lowenberg)  (see  "  Dacryocystitis  "). 

BRAILEY  AND  EYRE.— Lancet,  1897.  GROENOUW. — B.  d.  o.  G.,  1898;  A.  f.  O.,  Iii,  i, 
1901.  v.  AMMON. — Munch,  med.  Woch.,  1900.  HIROTA. — B.  mucosus  capsulatus,  Dissert. 
Halle,  1901.  GOURFEIN. — Rev.  med.  de  la  Suisse  Romande,  1902. 

Bacillus  pyocyaneus  has  been  found  in  several  cases  of  purulent 
keratitis.  Rapid  sloughing  of  the  cornea  usually  occurs,  followed  by 
panophthalmitis.  In  Sattler's  two  cases  pure  cultures  of  the  B. 
pyocyaneus  a  were  obtained  ;  in  two  cases  by  Bietti  and  McNab  the 
organism  was  the  B.  pyocyaneus  /3  (Ernst).  In  all  of  these  tests  of  viru- 
lence were  carried  out,  and  in  all  the  organisms  were  extremely  viru- 
lent. In  McNab's  case  panophthalmitis  and  rupture  of  the  globe 
followed  inoculation  of  the  rabbit's  anterior  chamber  in  forty-eight 
hours.  Herbert  has  found  the  organism  in  cases  of  superficial  keratitis 
(q.  v.),  but  the  variety  was  apparently  relatively  innocuous. 

SATTLER. — B.  d.  o.  G.,  1891  and  1892.  ERNST. — Z.  fur  Hygiene,  1887.  BIETTI. — Ann. 
di  Ott.,  xxviii,  1899.  McNAB. — Ophth.  Rev.,  xxiii,  1904;  K.  M.  f.  A.,  xlii,  1904. 


INFLAMMATION 

CONJUNCTIVITIS  IN  GENERAL 

Conjunctivitis  varies  greatly  in  degree — from  a  slight  hyperasmia 
with  watery  secretion,  due  chiefly  to  reflex  secretion  of  tears,  to  an 
intense  inflammation,  with  much  swelling  and  a  purulent  discharge.  It 
also  varies  greatly  in  duration,  being  transient  or  prolonged,  according 
to  the  nature  of  the  exciting  agent.  Anatomically,  however,  there  are 


THE    CONJUNCTIVA 


55 


certain  features  which  are  common  to  all  forms,  but  which  vary  in 
detail  according  to  the  acuteness  or  chronicity  of  the  process ;  whilst, 
superposed  upon  these  features  are  others  which  are  specific  for  certain 
types  of  conjunctivitis,  and  which  often  lie  at  the  basis  of  clinical 
classification,  e.g.  follicular,  membranous,  etc. 

The  fundamental  characteristics  are  for  the  most  part  those  of 
inflammation  in  general.  There  is  the  same  dilatation  of  blood-vessels 
and  lymphatics,  the  same  exudation  of  plasma,  lymphocytes  and 
leucocytes ;  the  variations  in  detail  depend  solely  upon  the  nature  of 
the  tissue.  The  substantia  propria,  consisting  as  it  does  of  very  loose 
tissue,  affords  little  resistance  to  the  outflow  of  fluid  from  the  engorged 
vessels.  Hence  swelling  (chemosis)  occurs  readily,  though  much  of  the 


FIG.  24. — CONJUNCTIVITIS,      x   10. 

From  a  specimen  by  Stock  (Freiburg  i.  B.).  The  eyeball  and  lids  were 
removed  post  mortem  from  a  case  of  pure  diplobacillary  conjunctivitis.  Note  the 
ectropion  of  the  lid,  and  intense  infiltration  of  the  adenoid  layer  of  the  conjunctiva ; 
the  latter  ceases  on  reaching  the  bulbar  conjunctiva.  (See  K.  M.  f.  A.,  xli, 
Beilageheft.) 

fluid  filters  through  into  the  conjunctival  sac,  mingles  with  the  tears  and 
secretions  of  the  various  glands,  and  forms  the  "discharge." 

The  adenoid  layer  already  contains  many  lymphocytes,  but  these 
are  enormously  increased  after  a  fe\y  hours'  irritation,  and  further  rein- 
forced by  polymorphonuclear  leucocytes  from  the  blood-vessels.  This 
leads  to  great  thickening  of  this  layer,  which  becomes  so  packed  with 
inflammatory  cells  that  the  supporting  tissues  are  only  seen  with 
difficulty.  The  limits  of  the  adenoid  layer  in  the  palpebral  conjunctiva 
are  well  shown,  the  swelling  ceasing  at  the  sulcus  subtarsalis.  The 
fibrous  layer  is  also  infiltrated,  but  its  denser  framework  prevents  the 
same  overcrowding  of  cells.  The  leucocytes  wander  still  farther  afield 


56  THE    PATHOLOGY   OF   THE   EYE 

and  invade  the  epithelium,  pushing  their  way  between  the  cells  ;  many 
succeed  in  reaching  the  free  surface,  and  add  their  quotient  to  the  con- 
junctival  secretion. 

The  inflammatory  cells  consist  of  many  different  sorts.  The  small 
round-cells,  or  lymphocytes,  are  increased  in  numbers,  probably  partly 
by  cell-division.  They  fill  the  perivascular  and  perineural  lymph 
sheaths,  and  in  these  situations  they  often  persist  long  after  the  original 
inflammation  has  subsided. 

The  polymorphonuclear  leucocytes  are  wanderers  from  the  blood- 
vessels, within  which,  also,  they  are  present  in  abnormally  large 
numbers.  Free  in  the  tissues,  they  adapt  themselves  to  their  surround- 
ings, the  nuclei  apparently  spreading  out  into  filaments  or  networks, 
which  have  been  regarded  by  Peters  as  coagulation  products,  though 
they  stain  deeply  with  nuclear  stains. 

Mast-cells  (Ehrlich)  also  are  increased  in  numbers.  These  are 
variously  looked  upon  as  leucocytes  or  as  of  connective-tissue  origin. 
Since  they  occur  in  the  blood  (0*5  per  cent,  of  the  leucocytes),  and  are 
increased  in  myelogenous  leukaemia,  it  seems  probable  that  they  are 
leucocytes.  They  are  characterised  by  the  presence  in  their  cytoplasm 
of  numerous  small  basophile  granules.  The  nucleus  is  relatively  small 
and  irregularly  trilobed.  The  cytoplasm  is  of  irregular  shape,  with 
short  thick  processes  ;  it  is  unstained  by  Ehrlich's  triacid  stain,  but 
with  basic  dyes  irregular  dark  blue  clumps  are  seen.  The  granules  are 
metachromatic,  staining  red  with  polychrome  methylene  blue,  orange 
with  Pappenheim's  stain  ;  l  with  Weigert's  elastic-tissue  stain  they  are 
bright  red,  with  Weigert's  fibrin  stain  blue. 

Plasma-cells  (Unna)  are  also  found,  and  are  greatly  increased  in  all 
chronic  inflammatory  conditions.  They  resemble  leucocytes,  but  are 
probably  of  connective-tissue  origin  (Unna),  and  indeed,  play  an  ex- 
tremely important  role  in  the  formation  of  scar  tissue.  Other  authors 
regard  them  as  derived  from  mononuclear  lymphocytes.  Their  cyto- 
plasm stains  blue  with  methylene  blue,  whilst  the  nucleus,  which  is 
eccentrically  placed,  stains  faintly,  appearing  as  a  clear  spot  with  small 
irregular  masses  of  chromatin  situated  chiefly  on  the  nuclear  membrane. 
The  cytoplasm  stains  dark  red  with  Pappenheim's  stain,  the  nucleus 
dark  blue,  and  the  nucleolus  red.  Plasma-cells  are  found  chiefly  near 
the  vessels,  and  especially  in  the  adenoid  layer. 

The  fixed  connective-tissue  cells  are  swollen.  The  interstitial  con- 
nective tissue  of  the  glands  is  infiltrated  with  round-cells  if  the  inflam- 
mation is  severe  (Wolfring). 

The  epithelium  shows  an  increase  in  goblet-cells,  though  this  is  not  so 
marked  as  in  chronic  inflammations.  The  stasis  in  the  blood-  and 
lymph-flow  leads  to  malnutrition,  the  epithelium  suffering  most.  Many 
of  the  superficial  cells  are  cast  off,  and  the  surface  becomes  irregular 
and  loses  its  shiny  appearance. 

It  also  loses  its  transparency,  so  that  the  Meibomian  glands  can  no 
longer  be  seen  through  it.  This  is  due  to  the  swelling,  which  also 


-1  Pappenheim's  Stain.—  One  part  of  methyl  green—  as  much  as  will  go  on  "  the  point  of 
—to  2  parts  of  pyronin,  in  half  a  small  test-tube  of  water.       Stain  five  minutes,  and 
then  decolourise  in  i  part  of  resorcin  to  half  a  test-tube  of  alcohol. 


THE   CONJUNCTIVA  57 

causes  an  increased  roughness,  the  normal  folds  and  furrows  being 
exaggerated.  The  unevenness  of  the  surface  may  cause  only  a  velvety 
appearance,  or  may  go  on  to  papilliform  projections.  These  are  of 
colossal  size  in  gonorrhoeal  conjunctivitis,  in  which  the  condition  is 
most  marked,  and  in  which  they  are  readily  accounted  for  by  the  ab- 
normal leucocytosis  which  takes  place.  In  later  stages  true  hypertrophy 
may  occur,  the  fibrous  tissue  being  increased  and  stretched,  though  the 
whole  disappears  eventually,  and,  in  the  absence  of  ulceration,  there  is 
no  cicatrisation.  This  formation  of  false  papillae  is  quite  different 
from  that  of  true  papillae,  as  in  spring  catarrh  (q.  v.). 

The  secretion  varies  greatly  in  different  types  of  conjunctivitis. 
At  first  it  is  watery  and  consists  chiefly  of  tears,  reflex  secretion  being 
increased.  These  are  soon  mixed  with  exuded  plasma,  which  becomes 
mucoid  by  admixture  with  the  secretions  of  an  increased  number  of 
goblet-cells.  Later,  the  addition  of  leucocytes  makes  the  discharge 
muco-purulent  or  even  purulent,  according  to  the  number  of  pus-cells. 
Haemorrhages  not  infrequently  occur,  especially  in  pneumococcic  con- 
junctivitis, and  red  corpuscles  are  then  often  found  in  the  secretion. 
Epithelial  and  mucous  cells  are  found,  and  many  of  the  cells  show 
fatty  globules  in  their  protoplasm.  In  the  new-born,  bile  pigments 
may  be  present  (icterus  and  ophthalmia  neonatorum).  In  all  cases 
many  organisms  are  found,  some  of  which  may  be  specific. 

Besides  the  papillary  elevations  in  acute  conjunctivitis,  true  follicles 
may  be  formed.  When  very  small  they  give  rise  to  the  vesicular  catarrh 
described  by  Arlt  (Mayvveg).  They  are  confined  to  the  tarsus.  In  the 
more  pronounced  form  they  cause  follicular  conjunctivitis  (q.  v.).  In  each 
case  they  are  due  to  aggregations  of  round-cells. 

Pustules  may  also  arise  around  the  cornea,  but  whether  inde- 
pendently of  phlyctenular  conjunctivitis  is  uncertain. 

In  the  later  stages  of  subacute,  and  in  chronic  conjunctivitis,  further 
changes  occur  in  the  epithelium.  The  number  of  goblet-cells  is  enor- 
mously increased,  especially  in  the  C.  bulbi.  They  may  be  packed 
close  together  and  form  nests.  The  normal  furrows  are  emphasised 
by  the  papillary  formations,  and  are  actually  increased  by  active  pro- 
liferation of  the  epithelium.  In  this  manner  gland-like  tubular  depres- 
sions are  formed,  often  appearing  to  branch  in  all  directions.  They 
are  probably  formed  by  the  canalisation  of  solid  downgrowths,  the 
central  cells  degenerating  and  disappearing.  Their  epithelium,  being 
partially  relieved  from  pressure,  becomes  glandular  in  type,  and  contains 
many  mucous  cells.  The  tubules  never  transgress  the  adenoid  layer, 
and  always  have  a  definite  basement  membrane.  A  double  layer  of 
epithelium  can  usually  be  made  out,  so  that  they  are  not,  at  any  rate 
for  the  most  part,  true  glands.  The  mouths  often  become  stopped  up 
by  agglutination,  or  by  inspissated  secretion  and  debris.  In  this 
manner  a  pseudo-retention  cyst  (q.  v.)  is  developed  later.  It  becomes 
filled  with  mucus,  exudate,  epithelial  and  leucocytic  debris,  in  which 
calcareous  deposits  occur,  with  the  formation  of  concretions  (Fuchs, 
Wintersteiner)  (v.  infra). 

In  still  more  chronic  conditions,  especially  when  the  conjunctiva  is 
exposed  to  air  and  dust,  as  in  ectropion,  the  epithelium  changes  its 


58  THE    PATHOLOGY    OF   THE    EYE 

character  entirely,  and  becomes  exactly  like  that  of  skin.  Stratified 
epithelium  replaces  the  normal  kind ;  the  middle  layers  form  true 
prickle-cells,  whilst  the  superficial  ones  are  flattened,  those  actually  on 
the  surface  losing  their  nuclei.  Cornification  of  the  cells,  however, 
never  seems  to  occur  in  the  conjunctiva  palpebrarum. 

WOLFRING.— A.  f.  A.,  xxxi,  1895.  PETERS. — C.  f.  A.,  xxi,  1897;  K.  M.  f.  A.,  xl, 
1902.  STOCK. — K.  M.  f.  A.,  xli,  1903,  Beilageheft. 

(Edema  of  the  conjunctiva  occurs  to  a  less  or  greater  extent  in  all 
cases  of  conjunctivitis,  leading  to  chemosis  when  it  is  extreme. 
Cases  of  angioneurotic  oedema  have  been  described  (Black),  as  well  as 
other  aberrant  forms  (Holmes  Spicer).  These  have  not  been  submitted 
to  microscopical  examination.  In  many  the  ordinary  inflammatory 
signs  would  doubtless  be  present,  whilst  the  more  chronic  ones  may  be 
allied  to  cases  of  lymphoma  (Guaita). 

BURNETT. — A.  of  O.,  xxi,  1892.  GUAITA. — Ann.  di  Ott.,  xix,  1890.  BLACK. — Ophth. 
Rev.,  xiv,  1895.  TERSON. — Recueil  d'Opht.,  1899.  HOLMES  SPICER. — T.  O.  S.,  xviii, 


MEMBRANOUS  CONJUNCTIVITIS. 

We  have  already  had  occasion  to  refer  frequently  to  membranous 
conjunctivitis.  Like  membranous  inflammations  of  other  mucous 
membranes,  it  is  especially  associated  with  the  Klebs-Loffler  bacillus, 
but  it  often  results  from  the  activity  of  other  organisms,  amongst  which 
streptococci,  gonococci,  and  pneumococci  demand  special  mention.  It 
is  also  found  after  burns,  the  application  of  strong  caustics,  e.  g.  lime, 
jequirity,  etc. 

A  rare  form  of  great  interest  is  associated  with  herpes  iris  of  the 
skin,  though  the  skin  eruption  may  be  absent.  This  form  is  chronic, 
and  in  some  cases  recurs  frequently  ;  it  has  been  recently  investigated 
by  Hanke.  In  one  case  Gehrke  and  Kain  isolated  a  coccus  which, 
inoculated  upon  a  rabbit's  conjunctiva,  produced  membranes  there. 

The  membrane  consists  chiefly  of  a  fibrinous  network  with  leucocytes 
in  the  meshes.  The  epithelium  is  necrotic  and  separated,  remnants 
of  the  cells  being  found  in  the  membrane  (Fig.  25).  The  raw  surface 
bleeds  when  the  membrane  is  removed,  as  in  the  true  diphtheritic  cases. 
If  the  membrane  is  not  removed  artificially  it  is  raised  by  the  develop- 
ment of  granulation  tissue,  and  undergoes  hyaline  degeneration,  being 
finally  cast  off.  It  often  develops  again  quickly,  but  when  healing 
takes  place  the  granulation  tissue  is  covered  with  epithelium  from  the 
sides  in  the  ordinary  manner. 

In  the  severer  cases  the  subepithelial  tissue  also  contains  fibrinous 
networks,  and  the  peripheral  vessels,  as  well  as  being  dilated,  are  often 
blocked  with  hyaline  thrombi.  Extensive  necrosis  may  then  occur: 
the  fibrin  undergoes  hyaline  degeneration,  no  longer  staining  with 
fibrin  stains,  and  the  same  takes  place  in  the  connective  tissue.  Cica- 
trisation results  in  these  cases  in  permanent  scarring. 

Cases   of  atypical,  chronic  membranous  conjunctivitis   previously 


THE    CONJUNCTIVA 


59 


reported     by    Morton,    Howe,    Silcock    and    Maynard,    Batten,    etc., 
possibly  belong  to  this  category  (v.  p.  50). 

MASON. — R.  L.  O.  H.  Rep.,  vii,  1873.  FUCHS. — K.  M.  f.  A.,  xiv,  1876.  NETTLESHIP. 
— St.  Thomas's  Hosp.  Rep.,  1880.  GUIBERT. — Soc.  fran9_  d'O.,  1893.  BRONXER, 
MORTON. — T.  O.  S.,  xiii,  1893.  *HOWE.— T.  Am.  O.  S.,  1897.  BATTEN. — T.  O.  S.,  xviii, 
1898.  SILCOCK  AND  MAYNARD. — T.  O.  S.,  xx,  1900.  GEHRKE  AND  KAIN. — A.  f.  A.,  xxiv, 
1892.  *HANKE. — A.  f.  O.,  Hi,  2,  1901.  ROSCHER. — K.  M.  f.  A.,  xl,  1902. 


TRACHOMA 

Attention  was  first  seriously  directed  to  trachoma  in  Europe  by  the 
spread  of  the  disease  amongst  the  soldiers  engaged  in  the  Napoleonic 
wars.  Vetsch  (1807)  first  referred  to  the  "granulations,'"  which  struck 


'->•• 

'+:•: 


FIG.  25. — MEMBRANOUS  CONJUNCTIVITIS,      x   130. 

From  a  specimen  sent  by  Prof.  Fuchs.  It  is  a  case  of  herpes  iris,  and  is  prob- 
ably from  the  case  described  by  Hanke,  and  figured  in  A.  f.  O.,  lii,  2,  1901.  The 
surface  is  formed  by  a  layer  of  hyaline  material  derived  from  granulation  tissue ; 
the  epithelium  has  been  cast  off.  The  tissue  below  this  contains  numerous  very 
fine  vessels,  and  is  densely  infiltrated  with  leucocytes  ;  it  is  made  up  of  young 
connective  tissue  with  spindle-cells,  and  large  oval  cells  with  pale  nuclei. 

him  as  characteristic.  Mackenzie  described  the  epidemic  upon  the 
French  slave-ship  "  Rodeur "  in  1819.  Memoirs  relating  to  the 
epidemic  followed  from  Larrey  (1812),  Rust  (1820),  v.  Walther  (1821), 
and  Carl  Ferdinand  v.  Graefe  (1823).  Among  the  various  opinions 
held  upon  the  subject  in  the  early  part  of  the  century,  the  following 
may  be  mentioned: — J.  Miiller  (1821),  an  affection  of  the  mucous 
glandular  tissue  of  the  conjunctiva  ;  Eble  (1828),  proliferation  of  the 
"  papillary  bodies,"  described  first  by  him  ;  Duvillards  (1841)  compared 
it  with  chilblains;  Himly  (1843),  groups  of  small  sarcomata;  Hasner 
(1847),  an  herpetic  eruption  ;  Ruete  (1854),  a  plastic  exudation  of  the 


6o 


THE    PATHOLOGY   OF   THE    EYE 


submucous  tissue  ;  Lawrence  (1850),  actual  warts  ;  Pilz  (1856),  gela- 
tinous exudates ;  Arlt  (1856),  "gelatinous  exudates  in  the  form  of 
isolated  granules." 

Bend;?,  in  1858,  first  pointed  out  that  the  essential  cause  of  the 
uneven  surface  of  the  conjunctiva  was  to  be  found  in  innumerable  cir- 
cumscribed aggregations  of  lymphoid  cells.  On  account  of  their 
similarity  to  the  solitary  follicles  of  the  intestines,  he  called  them 
lymph-follicles.  Two  great  discussions,  which  are  not  even  yet  settled, 
have  arisen  out  of  this  discovery,  viz.  (i)  whether  lymph-follicles  occur 
normally  in  the  conjunctiva;  and  (2)  whether  foliicular  conjunctivitis 
and  trachoma  are  one  and  the  same  disease  or  not. 

From  this  time  research  was  principally  directed  towards  settling 
the  exact  nature  of  the  trachoma  follicle.  In  1878  Berlin  and  Iwanoff 
published  papers  simultaneously,  drawing  attention  to  glands  which 
they  regarded  as  specific  (trachoma  glands).  These  were  nothing  more 
than  the  now  familiar  folds  and  furrows,  Henle's  glands,  and  new- 
formed  inflammatory  glands,  which  are  met  with  under  the  most 
various  circumstances.  This  was  pointed  out  by  Leber,  and  was 
clearly  proved  by  a  comparison  with  the  normal  conjunctiva  by 
Jacobson. 

In  spite  of  many  differences  of  opinion  as  to  details  in  the  structure 
of  the  trachoma  follicle,  nearly  all  observers  agreed  that  it  was 
impossible,  on  purely  anatomical  grounds,  to  diagnose  between 
foliicular  conjunctivitis  and  trachoma.  Saemisch  (1876),  however, 
drew  a  sharp  distinction  between  them  :  "  follicles  "  disappear,  leaving 
no  trace  behind,  "  granulations  "  invariably  leave  scars  ;  "  follicles  " 
are  encapsuled,  "granulations  "  have  no  capsule,  and  are  genuine  new 
formations.  Raehlmann  (1883,  sqq.),  at  the  opposite  extreme, 
asseverates  the  identity  of  the  two  conditions.  Sattler  (1881)  considers 
the  trachoma  follicle  a  thing  sui  generis,  such  as  never  occurs  in  the 
normal  conjunctiva.  Mandelstamm  (1883)  regards  foliicular  conjunc- 
tivitis as  the  precursor  of  trachoma,  the  follicle  being  a  mere  filling  of 
pre-existing  lymph  spaces  under  the  stimulus  of  inflammation.  Rhein 

(1888)  supports  Raehlmann  on 
anatomical  grounds,  but  these 
do  not  suffice  to  establish  the 
identity  of  the  conditions,  as 
shown  by  Schmidt-Rimpler  at 
the  International  Congress  at 
Berlin  (1890).  It  is  perhaps 
easier  for  us  in  England  to  be 
convinced  of  the  absolute  duality 
of  the  two  complaints,  than  for 
those,  like  Raehlmann,  who  work 
in  dense  trachomatous  areas. 

Trachoma  occurs  in  two 
forms :  papillary,  limited  to  the 
C.  tarsi,  in  which  the  surface 
appears  velvety  from  the  formation  and  hypertrophy  of  pseudo- 
papillae,  which  may  form  raspberry-like  projections ;  and  granular, 


FIG.  26. — TRACHOMA,  \\  in.  obj. 
After  Ridley  (T.  O.  S.,  xiv,  pi.  i),    show- 
ing the  epithelium  dipping  down  between  the 
follicles. 


THE    CONJUNCTIVA  61 

due  to  the  formation  of  grey,  translucent,  hemispherical  bodies, 
much  resembling  frog's  spawn  or  grains  of  boiled  sago.  The  latter 
are  found  chiefly  in  the  folds  of  transition,  arranged  in  rows  like 
a  string  of  pearls.  In  the  C.  tarsi  the  granules  are  also  present,  but 
owing  to  the  adherence  of  the  conjunctiva  to  the  tarsus,  they  are 
smaller  and  bright  yellow,  or  hidden  by  papillae.  These  have  been 
called  "  elementary  or  primary  granulations  "  (v.  Graefe,  Jacobson), 
an  unfortunate  term,  since  they  are  not  necessarily  immature  follicles, 
but  are  merely  restricted  in  growth  on  account  of  their  anatomical 
surroundings.  Moreover  they  are  especially  characterised  by  a  tendency 
to  grow  deeply  and  involve  the  tarsus,  and  are  pathognomonic  of 
trachoma,  since  follicles  never  occur  here  in  follicular  catarrh. 

The  granulations  usually  cease  in  a  sharp  horizontal  line  near  the 
fornix,  where  the  character  of  the  epithelium  changes,  stratified 
epithelium  being  apparently  unsuited  to  their  development.  They 
generally  commence  in  the  lower  lid,  either  in  the  groove  between  the 
edge  and  the  tarsus  or  near  the  fornix.  They  then  spread  to  the  angles, 
especially  the  inner,  involving  the  caruncle  and  its  neighbourhood. 
They  grow  similarly  in  the  subtarsal  groove  below  the  upper  tarsus, 
and  reach  their  most  profuse  development  above  the  upper  tarsus, 
between  it  and  the  fornix.  Growth  upon  the  upper  tarsus  is  latest,  and, 
as  mentioned,  least  striking. 

Papillae  and  granulations  commonly  occur  together,  the  former 
most  marked  upon  the  tarsus,  the  latter  in  the  fornices.  Affection  of 
the  C.  bulbi  at  the  limbus  follows,  with  the  development  of  pannus 
trachomatosus  (q.  v.). 

The  papillas  and  granulations  ultimately  retrogress,  with  the  for- 
mation of  fine  cicatricial  bands.  These  appear  as  narrow  white  striae, 
forming  a  delicate  network  in  the  hypersemic  conjunctiva  of  the  tarsus. 
They  grow  in  number  and  breadth,  invading  the  hyperaemic  islands, 
until  the  whole  becomes  pale,  thin,  and  smooth,  the  amount  of 
cicatrisation  corresponding  with  the  amount  of  the  hypertrophy.  The 
white  bands  are  less  apparent  in  the  fornices  :  here  the  conjunctiva 
becomes  pale  and  flat,  the  normal  folds  being  smoothed  out  and  the 
conjunctiva  seriously  shortened.  This  shortening,  combined  with 
cicatricial  changes  in  the  tarsus,  leads  to  entropion,  whilst  the  earlier 
thickening  and  hypertrophy  may  cause  ectropion,  usually  limited  to  the 
lower  lid.  The  shortening  may  even  obliterate  the  fornix  and  lead  to 
symblepharon  posterius  ;  whilst  the  abolition  of  secretory  functions 
may  eventuate  in  xerosis  or  xerophthalmia. 

The  essential  anatomical  feature  of  all  clinical  types  of  trachoma, 
whether  papillary,  granular,  mixed,  gelatinous,  etc.,  is  the  trachoma 
follicle,  which  is  never  absent,  though  it  varies  in  detail. 

The  Trachoma  Follicle  (Fig.  26) . — Arising  from  the  discovery  by  Bendz 
in  1858  of  the  characteristic  lymph-follicles  is  the  question  of  their 
occurrence  in  the  normal  conjunctiva.  As  already  stated  (p.  34),  they 
are  normal  in  some  animals,  and  poorly  developed  follicles  are  not 
uncommon  in  apparently  normal  human  conjunctivae.  They  are 
regarded  as  physiological  by  W.  Krause,  Baumgarten,  Stohr,  etc. ;  and 
as  invariably  pathological  by  Waldeyer.  In  treating  of  so  notoriously 


62  THE    PATHOLOGY    OF  THE    EYE 

unstable  a  tissue  as  lymphoid  tissue,  difficulty  in  arriving  at  a  final 
decision  is  not  surprising.  Suffice  it  to  say  that  trachoma  is  accom- 
panied by  an  enormous  and  wide-spread  development  of  such  follicles. 
Here  they  form  larger  or  smaller  nodules,  varying  much  in  appearance 
according  to  age  and  size.  They  lie  in  the  adenoid  layer,  and  lift  up  the 
epithelium  above  them. 

Wolfring  (1868)  came  to  the  conclusion  that  follicles  do  not 
occur  normally,  but  that  they  are  the  essential  feature  of  trachoma. 
They  occur  in  the  pre-formed  adenoid  layer  of  the  conjunctiva,  and,  like 
those  of  the  intestine,  consist  of  (i)  a  stroma,  viz.  the  reticular  tissue  of 
the  adenoid  layer  of  the  conjunctiva ;  (2)  lymphoid  elements  in  the 
meshes  of  the  stroma  ;  (3)  vessels,  which  surround  the  follicle,  and 
send  sparse  capillaries  into  it ;  and  (4)  an  inconstant  fibrous-tissue 
capsule.  Thus  early  were  the  essential  elements  of  the  trachoma 
follicle  described,  but  each  of  these  constituents  has  been  the  field  of 
heated  controversy. 

i.  The  stroma. — Whilst  most  authors  agree  as  to  the  existence  of  a 
stroma,  they  differ  as  to  its  distribution  and  constitution. 

Jacobson  describes  a  fine  network  which  pervades  the  inflamed 
area  and  extends  to  the  tips  of  the  papillae,  enclosing  the  infiltrating 
cells  in  its  meshes.  It  is  best  seen  by  hardening  in  chromic  acid,  or  in 
Miiller's  fluid  and  alcohol,  or  in  alcohol  alone  ;  and  parts  can  be  seen 
well  in  teased  preparations.  By  pencilling  out  the  enmeshed  cells  in 
thin  sections  a  fine  reticulum  is  obtained,  at  the  nodal  points  of  which 
nuclei  are  often  seen.  The  meshes  are  smaller  and  longer  at  the 
periphery  of  the  follicle,  and  wider  near  the  centre.  Jacobson's 
description  agrees  with  the  earlier  ones  of  Blumberg,  Berlin,  Iwanoff, 
and  with  the  later  ones  of  Sattler,  Raehlmann,  v.  Michel,  etc. 
Raehlmann  describes  a  distinct  net\vork  in  young  follicles,  consisting  of 
branching  fibres  with  nodular  or  stellate  swellings  at  the  divisions,  the 
latter  often  having  pale  oval  nuclei. 

Mandelstamm  (1883)  denied  the  presence  of  a  stroma,  and 
attributed  the  appearances  to  fine  branching  processes  of  the  cells, 
which  interlocked  and  simulated  a  reticulum. 

Villard  (1896)  and  Pick  (1897)  also  deny  that  there  is  a  stroma,  the 
reticulum  being  an  artefact,  due  to  coagula.  There  can  be  no  doubt 
that  there  is  a  stroma  in  the  periphery  of  the  follicles,  and  that  this 
increases  very  markedly  with  age.  The  fibrous  tissue  here  contains 
fixed  connective-tissue  cells,  mostly  spindle-shaped  or  stellate,  with 
pale,  round,  oval,  or  long  nuclei.  Villard  finds  that  few  fibres  pass 
inwards  from  this  peripheral  capsule,  and  that  these  belong  chiefly  to 
the  vessels,  adhere  to  them,  and  have  only  a  few  long  nuclei.  One 
often  sees  a  very  fine  network  with  narrow  meshes  in  the  centre, 
especially  in  preparations  fixed  with  Flemming's  solution.  This  has  no 
nuclei,  and  is  due  to  coagulation.  Pick  agrees  with  these  conclusions; 
he  never  found  a  reticulum  in  fresh  follicles,  even  by  pencilling  out  the 
cells.  He  compares  the  coagula  with  those  found  in  other  pathological 
processes,  e.  g.  coagula  of  blood  proteids  in  tubercle  (Schmaus  and 
Albrecht),  but  this  does  not  seem  a  very  fortunate  analogy. 

Addario  (1900)  cut  serial  sections  of  young  nodules,  and  found  that 


THE    CONJUNCTIVA  63 

the  faintly  stained  centre  contained  many  cellular  elements,  lying  fairly 
far  apart,  so  that  an  intercellular  stroma  could  be  clearly  distinguished. 
This  sprang  from  the  peripheral  strands,  which  continually  divided  as 
they  passed  inwards,  until  they  finally  enclosed  only  two  or  three  cells, 
and  even  these  were  separated  by  fine  protoplasmic  processes  of  the 
connective-tissue  cells.  These  results  support  those  of  Moauro  (1891), 
and  are  opposed  to  those  of  Villard  and  Pick.  Towards  the  periphery 
of  the  young  nodule  the  fixed  cells  are  small  and  spindle-shaped ; 
where  the  fibres  divide  they  are  often  triangular.  Other  large  cells — 
the  trachoma  corpuscles — Addario  considers  to  be  fixed  connective- 
tissue  cells  (v.  infra). 

The  arrangement  of  the  fibrous  tissue  is  best  seen  in  sections  stained 
by  van  Gieson's  method.  The  fuchsin-stained  fibres  are  then  seen  to 
be  almost  limited  to  the  peripheral  parts. 

2.  The  cells. — Jacobson  and  Sattler  distinguished  two  types  of  cells  : 
quite  small  lymphoid  cells,  with  small,  round,  deeply  stained  nuclei ; 
and  much  larger  cells,  with  large,  round,  pale  nuclei,  which  are 
distributed  more  or  less  regularly  through  the  follicle.  The  smaller 
cells  are  closely  packed  at  the  periphery,  so  that  a  deeply  stained 
peripheral  zone  is  usually  well  marked  off.  The  larger  cells  are 
scattered  amongst  the  looser  small  cells  in  the  interior,  which  therefore 
looks  paler. 

Villard  further  subdivided  the  cells  thus : — (a)  Lymphocytes, 
arranged  in  typical  fashion,  or  forming  small  secondary  nodules ;  (b) 
mononuclear  leucocytes  of  varying  size,  and  often  epithelioid,  forming 
the  main  mass  of  the  follicle  ;  (c)  large  cells 
of  unknown  origin,  found  sparsely  in  the 
middle  of  the  granulation,  with  a  voluminous 
nucleus  and  a  large  cell-body ;  they  have 
protoplasmic  processes  which  unite  with 
those  of  other  cells,  and  form  a  network 
within  the  reticulum  ;  (d)  phagocytes,  volu- 
minous cells  of  varying  shape,  with  different 
cell-inclusions,  doubtless  products  of  meta- 
bolism ;  (e)  accessory  elements,  multinuclear 
cells,  eosinophile  cells,  polymorphonuclear 
leucocytes,  etc.  (c)  and  (d)  are  probably 
identical,  and  will  be  considered  together. 

(a)  Lymphocytes  (Fig.  27). — These  are 
small  mononuclear  cells,  with  little  cyto- 
plasm. The  nucleus  measures  4 — 7  ju,  and 
stains  very  deeply.  They  never  show  karyo- 
kinetic  figures.  The  lymphocytes  form  the 

i  •    f  .'.  r  ,i  •    i          i  i         Herbert.    T.  O.  S.,    xix.      Por- 

chief  constituent  of  the  peripheral  zone,  and  tion  of  a  trachoma  follicle,  stained 
are  arranged  here  in  rows  between  the  con-  by  Unna's  protoplasm  method, 
nective-tissue  fibres.  They  are  few  in  the  Lymphocytes  are  seen  as  rings 
centre,  but  increase  in  numbers  in  cicatris-  »™nZst  the  *****  of  broke"-down 
ing  follicles  (Pick). '  At  the  edge  of  the 

follicles  the  lymphocytes  and  their  nuclei  are  sometimes  seen  much 
elongated,  giving  evidence  of  amosboid  movements,  the  cells  being 


FIG.  27. — T 


,    o-  - 


64  THE    PATHOLOGY    OF   THE    EYE 

caught    in    the    act    of  streaming   out    into    the    surrounding    tissues 

(Herbert).     It    is    questionable  whether  these    are    not    polymorpho- 

nuclear  leucocytes. 

(6)  Mononnclear  leucocytes  (Fig.  28). — These  are  the  characteristic  cells 

of  the  follicle.     They  have  well-marked  cell-bodies  (16 — 18  ^t),  which 

are  round,  or  polygonal  by  mutual  pressure. 
They  often  appear  epithelioid,  especially  in 
preparations  hardened  by  Flemming's  solu- 
tion. Their  nuclei  measure  7 — 12  /*,  stain 
faintly,  and  often  show  karyokinetic  figures. 
The  larger  the  nucleus  the  fainter  it  stains, 
and  degeneration  of  the  nucleus  apparently 
occurs  when  a  certain  size  is  attained 
(Leber).  The  nucleus  is  always  granular, 
and  some  cells  have  quite  small  nuclei,  about 
one  fifth  the  usual  size.  These  cells  may 
be  regarded  as  different  stages  of  the  peri- 


FIG.  28.— TRACHOMA.   Zeiss  D  =    pheral   lymphoid  cells  (Addario)   (lympho- 
«  m-  ObJ-  gonia,  Benda).     Herbert  compares  the  epi- 

After  Ridley     Part  of  a  tra-    thelioid  cells  with  plasma-cells,  with  which 

choma  follicle,  showing  epithelioid       ,  ,  .  r     '  , 

cells  they  have  many  points  01  resemblance. 

The  cytoplasm  is  less,  but  stains  darkly 

with  basic  dyes.  The  nuclei  of  the  larger  cells  show  several  large 
nucleoli.  When  the  protoplasm  is  stained  with  polychrome  methylene 
blue  two  or  more  closely  packed  nuclei  may  be  made  out,  probably 
due  to  amitotic  division  (Herbert).  Whilst  resembling  plasma-cells, 
they  are  not  identical ;  typical  plasma-cells  do  not  occur  in  the  follicles, 
but  are  found  in  the  diffuse  infiltration.  In  places  rows  of  plasma- 
cells  are  found  close  beneath  the  epithelium,  separated  by  bundles  of 
fibrous  tissue  (cf.  Fig.  37).  These  are  Leber's  half-moon  cells  (v.  infra). 

Division  of  the  epithelioid  cells  gives  rise  to  the  lymphocytes,  all 
transitions  being  seen  in  a  follicle  (Herbert).  Even  in  the  boundary 
zone,  and  in  the  accumulations  in  lymph  vessels,  where  the  smallest 
lymphocytes  are  found,  there  are  always  a  few  epithelioid  cells. 

(c)  Large  cells  (phagocytes  [Villard,  Pick],  large  connective-tissue  cells 
[Addario],  Korperchenzellen  [Leber],  trachoma  corpuscles)  (Fig.  29). — 
These  are  much  larger  cells,  often  very  numerous,  scattered  about  the 
interior  of  the  follicle.  They  have  a  large  irregular  cell-body,  with  long 
protoplasmic  processes.  The  round  or  oval  nucleus  is  very  large,  pale, 
and  homogeneous,  with  one  or  two  nucleoli.  The  cytoplasm  contains 
vacuoles  and  very  various  cell  inclusions,  e.  g.  fragmentary  nuclei,  red 
corpuscles,  pigment,  etc.,  often  in  grotesque  shapes. 

Omeltschenko  considered  that  they  must  be  derived  from  epithelial 
cells.  Pick,  on  the  grounds  of  general  pathology  and  the  differences 
exhibited  by  granulation-tissue  cells,  regarded  them  as  derived  from 
cells  of  the  conjunctival  stroma  or  from  endothelial  cells  of  the 
vessels. 

Addario  considered  them  fixed  connective-tissue  cells.  Some 
adhere  to  the  fibres  of  the  stroma ;  others  are  irregularly  star-shaped, 
and  only  touch  the  fibrous  tissue  by  their  processes ;  in  others  the  long 


THE    CONJUNCTIVA  65 

thin  processes  extend  far  from  the  cell-body.  The  cell-inclusions  are 
always  surrounded  by  a  small  clear  zone.  These  cells  are  always  found 
in  the  first  stage  of  development  of  the  follicle,  and  become  fewer  later. 
Their  relationship  to  the  reticulum  points  to  their  connective-tissue 
origin,  and  intermediate  forms  between  them  and  the  fixed  cells  are 
common.  These  are  long  oval  cells,  with  pale  oval  homogeneous 
nuclei,  with  a  nucleolus.  Where  the  fibres  divide,  the  large  cells  are 
often  triangular,  and  their  processes  cling  to  the  fibres.  Similar  cells 
were  found  by  Flemming  (1885)  in  normal  lymphatic  nodules,  and  by 
Moauro  in  trachoma  in  1890. 

Leber  very  wisely  called  these  cells  "  Korperchenzellen,"  on  account 
of  their  cell-inclusions,  a  name  which  did  not  prejudice  any  theory.  He 
remarks  that  Pfeiffer  (1894)  probably  referred  to  these  when  describing 


FIG.  29. — TRACHOMA,      x  260. 

From  a  specimen  by  Herbert.  The  triangular  cell  in  a  large  space  near  the 
centre  contains  amorphous  hyaline  granules  ;  below  this  and  a  little  to  the  right  is 
a  cell  containing  globules  of  hyaline  material. 

some  parasitic  appearances  which  he  found  both  in  vaccine-inoculation 
of  the  cornea  and  in  trachoma.  Leber  found  them  in  other  lymph- 
follicles  of  the  conjunctiva;  and  they  were  also  found  by  Heidenhain  in 
the  mucous  membrane  of  the  intestine,  and  by  Hoyer  in  lymphatic  glands. 
Greeff  was  struck  by  their  resemblance  to  Protozoa,  and  showed  them 
to  specialists,  who  were  surprised  at  the  resemblance.  Greeff  says  that 
they  are  not  found  outside  the  follicles.  This,  however,  is  not  true. 
Herbert  has  found  them  in  diffuse  lymphoid  infiltration,  but  here  the 
cells  are  not  so  swollen,  the  cell-inclusions  are  not  collected  into  groups, 
and  without  special  staining  are  liable  to  be  overlooked.  The  inclu- 
sions are  hyaline  bodies ;  some  are  perfectly  spherical  globules  formed 
in  swollen  plasma-cells  (Fig.  29) ;  others  are  angular,  formed  in  long 


66  THE    PATHOLOGY   OF   THE    EYE 

connective-tissue  cells.     In  any  case  the  "  Korperchenzellen  "  are  of 
connective-tissue  origin  (Herbert). 

(d)  Accessory  dements. — These  are  inconstant  constituents  of  tra- 
choma follicles,  and  include  the  following  : 

(a)  Polymorphonuclear  leucocytes  are  found  rarely ;  they  are  evi- 
dence of  pyogenic  infection. 

((5)  Mast-cells  are  found  at  the  periphery,  especially  of  large  follicles. 
They  are  a  normal  constituent  of  the  conjunctiva. 

(7)  Villard  found  large  cells  with  eosinophile  granules  in  a  single  case. 

(e)  Giant-cells  have  occasionally  been  found  (Villard,  Pick).     They 
have  from  three  to  six  large,  deeply  staining  nuclei  in  a  small  mass  of 
cytoplasm,  and  probably  arise  from  the  epithelioid   cells  by  nuclear 
division  without  cell-division  (Pick). 

(e)  Irregular,  deeply  staining  fragments  of  nuclei  are  often  found 
scattered  in  the  follicle. 

It  may  be  noted  that  all  these  cells  are  of  mesoblastic  origin,  none 
being  derived  from  epiblast  (Villard). 

The  youngest  or  "  initial "  nodule  consists  of  a  minute  round 
aggregation  of  cells,  about  0*24  mm.  (Addario)  or  0*3  mm.  (Villard)  in 
diameter.  The  distinction  between  the  darker  peripheral  zone  (0*65 
mm.)  and  the  clearer  centre  (o'2O  mm.)  is  very  early  apparent  (Addario). 
The  clear  part  (0*16  mm.)  possesses  all  the  characters  of  an  ordinary 
lymphatic  nodule,  consisting  of  epithelioid  cells  with  large  nuclei,  many 
of  which  are  undergoing  mitosis.  Some  of  these  contain  cell-inclusions. 
Blood-vessels,  which  are  absent  in  the  youngest  nodules,  may  be  seen 
developing,  but  the  stroma  is  seen  with  difficulty,  owing  to  the  crowd- 
ing together  of  the  cells.  The  periphery  contains  smaller  cells  than 
the  centre,  and  these  have  granular,  deeply  stained  nuclei.  They  are 
much  more  numerous  than  in  the  initial  nodules,  but  the  stroma  can  be 
made  out  continuous  with  the  connective  tissue  of  the  surrounding 
conjunctiva. 

As  the  nodule  increases  the  central  part  grows  much  more  rapidly 
than  the  periphery,  having  a  diameter  of  0*35  mm.  in  a  nodule  of 
0*40  mm.  Karyomitoses  are  numerous.  The  surrounding  fibrous 
tissue,  which  is  looser  in  the  periphery  of  the  smaller  and  closer  in 
that  of  the  larger  nodules,  forms  no  true  capsule,  but  is  in  direct  con- 
tinuity with  the  submucosa. 

In  nodules  of  o-g6 — 1*28  mm.  the  trachoma  corpuscles  contain 
many  more  cell-inclusions  than  in  the  smaller  nodules.  These  consist 
principally  of  degenerated  nuclei  (Addario),  but  this  is  denied  by 
Flemming  for  lymphatic  nodules  and  Peyer's  patches,  their  true  nature 
being  as  yet  undetermined.  Some  contain  two  unequal  nuclei,  possibly 
due  to  fragmentation.  Others  contain  pigment  granules,  as  was  also 
found  in  lymphatic  nodules  by  Flemming.  The  pigment  is  probably 
the  result  of  the  intra-cellular  destruction  of  red  blood-corpuscles. 

A  small  number  of  long,  irregular,  polynuclear  cells  with  very  little 
protoplasm  may  be  seen  ;  they  consist  of  little  more  than  groups  of  two, 
three,  or  more,  pale  homogeneous  nuclei,  each  with  a  nucleolus.  They 
are  probably  young  connective-tissue  cells,  or  precursors  of  the  trachoma 
corpuscles  (Addario). 


THE    CONJUNCTIVA  67 

3.  The  vessels. — Blood-vessels  were  described  in  the  follicles  by 
Wolfring,  and  this  was  confirmed  by  Blumberg,  Jacobson,  Sattler, 
Leber,  etc.  Iwanoff  alone  failed  to  find  them.  Kaehlmann  found  the 
follicles  poor  in  vessels,  v.  Michel  only  vascularised  at  the  periphery, 
and  Villard  very  richly  supplied. 

The  fully  developed  follicles  have  a  rich  network  of  blood-vessels 
around  them,  from  which  numerous  capillaries  pass  inwards,  disappear- 
ing towards  the  centre.  They  are  very  thin-walled,  with  an  endo- 
thelial  lining,  and  rarely  muscle-fibres  (Pick).  Probably  they  are  early 
obliterated,  thus  aiding  resolution  (Greeff).  Old  soft  follicles  often 
have  degenerated  and  obliterated  vessels. 

Authors  differ  as  to  the  relative  proportion  of  lymph-vessels. 
Villard's  contention  that  the  follicles  lie  in  the  course  of  lymph-vessels 
is  of  great  importance  as  regards  their  true  status  as  lymph-follicles. 


FIG.  30. — TRACHOMA. 

Herbert,  T.  O.  S.,  xix.  Origin  of  a  trachoma  follicle  in  a  lymph-vessel. 
A.  Collection  of  small  lymphocytes  in  a  lymph-vessel.  B.  A  less  denned  group  of 
lymphocytes,  a,  a.  Larger  cells  undergoing  mitosis,  c.  Thickly  distributed  large 
plasma-cells.  D.  Epithelium. 

This  theory  is  supported  by  Herbert  (Fig.  30).  Probably  the  smaller 
nodules  are  entirely  nourished  by  lymph.  It  is  certain  that  the 
lymphatics  below  and  upon  the  surface  are  often  widely  dilated,  and 
packed  with  leucocytes.  The  superficial  ones  explain  the  so-called 
"  vesicular  granulations  "  of  the  older  authors  (Raehlmann),  and  are 
rarer  than  the  deep  dilated  ones.  Lymphatic  spaces  with  an  endo- 
thelial  lining  cannot  usually  be  made  out  within  the  follicle. 

4.  The  capsule. — The  existence  of  a  definite  capsule  was  affirmed  by 
Wolfring,  and  confirmed  by  Blumberg,  Berlin,  and  Iwanoff.  Jacobson 
and  Raehlmann  found  no  true  capsule,  but  special  small  peripheral 
cells,  which,  according  to  the  latter  author,  became  changed  into 
spindle-shaped  ceils  and  fibres.  Such  a  metamorphosis  of  lymphoid 
into  connective-tissue  cells  is  contrary  to  general  pathological  teaching. 


68 


THE    PATHOLOGY   OF   THE    EYE 


Saemisch  denied  any  capsule  to  his  "  granulations,"  whereas  "follicles  " 
have  capsules. 

The  periphery  of  the  nodules  is  distinctly  marked  off  by  the  zone  of 
lymphocytes,  arranged  in  concentric  rows.  There  is  connective  tissue 
between  these  cells,  but  it  forms  no  true  capsule.  It  surrounds  only 
that  part  which  impinges  upon  the  submucosa,  and  sections  may  be 
seen  which  give  the  appearance  of  a  complete  sheath.  Serial  sections, 
however,  show  that  this  consists  of  submucous  fibrous-tissue  bundles, 
which  are  distorted  and  displaced.  In  fact,  they  run  continuously  over 
the  nodules,  and  on  the  surface  of  the  conjunctiva  they  run  parallel 
to  the  adenoid  layer  (Addario).  In  these  respects  the  granulations 
differ  in  no  degree  from  lymphatic  nodules.  The  bundles  are  separated 
from  one  another  by  the  infiltrating  cells  rather  than  pressed  together 
by  them  (Greeff). 

As  the  nodules  become  older  a  true  capsule  is  undoubtedly  formed, 
which  reaches  its  maximum  in  the  regressive  stages.  This  is  the  com- 
mencement of  cicatrisation  ;  it  does  not  usually  develop  equally  in  the 
periphery,  but  begins  on  the  deeper  surface. 

The  epithelium. — The  epithelium  is  usually  thickened,  both  on  the 
surface  of  the  papillae  and  granulations,  and 
also  in  the  depressions  (Fig.  31).  True 
papillae  are  often  superposed  upon  the  pseudo- 
papillae  formed  by  the  folding  of  the  increased 
area  of  the  conjunctiva.  In  the  depressions 
the  normal  duplex  layer  of  epithelium  is 
maintained,  but  on  the  summits  the  cylin- 
drical cells  are  lost  early  (Fig.  33).  They 
are  replaced  by  layers  of  rounded  (deep)  and 
flattened  (superficial)  cells  derived  from  the 
basal  cells,  which  assume  a  cubical  or  even 
cylindrical  form,  and  show  many  karyomi- 
toses.  The  overgrowth  of  epithelium  in  itself 
conduces  to  the  formation  of  cockscomb- 
like  sprouts.  Rarely  the  epithelium  becomes 
quite  like  that  of  the  epidermis,  with  the 
development  of  a  superficial  corneous  layer 
(Baumgarten).  In  such  cases  the  cells  of 
the  middle  layer  are  prickle-cells  with  inter- 
cellular lymph-channels  in  which  leucocytes 

very  chronic  trachoma.  A.  Mar-  are  often  found  (Villard).  The  goblet-cells 
ginal  strip,  reaching  up  to  the  are  much  increased  (Fig.  32),  especially  in 
sukus  subtarsalis,  with  thick  tne  depressions,  and  the  whole  epithelium  is 

stratified    epithelium  resembling  ,     ,       •,,     / 

epidermis,     a.  Tarsus.     B.  Lym     pervaded  With  leucocytes. 

phoid  portion,  showing  a  ten-  Follicles  do  not  occur  where  the  epi- 
dency  to  papillary  formation,  thelium  is  normally  stratified.  This  is 

doubtless  due  to  the  fact,  insisted  upon  by 
Mutermilch,  that  adenoid  tissue  is  not  found 
immediately  beneath  epidermoid  epithelium 
Mucous  epithelium  is  specially  constituted  for 


FIG.  31. — TRACHOMA. 
Herbert,       T.      O.      S., 
Upper  palpebral   conjunctiva 


numerous  i 
growths,  and 
tration. 


anywhere  in  the  body. 


secretory  purposes,  and  demands  a  rich  vascular  and  lymphatic  supply. 


THE    CONJUNCTIVA 


69 


The  active  regeneration  of  this  epithelium  under  the  influence  of  irrita- 

tion   may  become  excessive,   leading  to  a   change  in  type.       In  this 

manner  its  powers  of  resistance 

are  increased,  and  a  new  balance 

is  set  up  between  the  epithelium 

and     its     substratum     (Muter- 

milch),  at  the  loss,  however,  of 

its    proper    secretory    function, 

and  the  development  of  condi- 

tions allied  to  those  of  skin. 

Necrosis  of  the  epithelium 
was  described  by  Remy  over  the 
follicles.     This  only  occurs  as  a 
secondary  phenomenon  by  the 
mechanical  pressure  of  the  grow- 
ing  follicle,    whereby    the    base-        FIG.  32.—  TRACHOMA.     Zeiss  E  =  i-in.  Obj. 
meilt  membrane  and  epithelium        After    Ridley.      Epithelium    from    the    fornix, 
are    injured    and    caused    to    de-    showing  goblet-cells.     Prepared  by  Foa's  method. 

generate.    Ulceration,  described 

by  Raehlmann  as  a  frequent  precursor  to  resolution,  probably  does  not 

happen.     The  epithelium   is  often   mechanically  broken,  but   rapidly 

heals. 

Solid  epithelial  downgrowths  are  either  the  result  of  healing  of 
such  excoriations  (Raehlmann,  Nuel),  or  more  probably  are  due  to 
inflammatory  hyperplasia. 

Gland-like  depressions  are  enormously  increased.  These  are  mostly 
folds  and  furrows  (Henle's  glands),  but  true  tubular  glands  are  also 
formed,  as  in  so  many  inflammatory  conditions  of  the  conjunctiva 
(Fig.  33).  Attention  was  unduly 
directed  to  these  structures  in  1878 
by  Berlin  and  Iwanoff,  who  regarded 
them  as  the  essential  features  of  the 
disease  (Berlin  and  IwanofFs  tra- 
choma glands).  Berlin  thought  that 
they  were  developed  from  pre-exist- 
ing glands,  whilst  Iwanoff  thought 
they  were  new  formations.  Their 
relation  to  trachoma  is  in  no  sense 
specific,  but  the  actual  increase  of 
true  tubular  depressions  in  this  and 
allied  conditions  must  be  admitted. 
The  mouths  of  these  depressions 
readily  become  blocked  mechani- 
cally, and  in  this  manner  the  mucus, 
leucocytes,  shed  epithelial  cells,  and 
other  debris  are  retained  within  the 


FIG.  33.- 


-TRACHOMA. 
Obj. 


Zeiss  AA  =  ^-i 


After    Ridley.      Showing    deepening    of 
the    crypts.      Most   of   the   epithelium   has 
at  the  blind  ends ;    what   re- 


lumen.      This    becomes    dilated,    and    mains  is  infiltrated  with  leucocytes'. 
cysts  are  formed.     These  may  also  be 

due  to  the  degeneration  of  the  central  cells  of  solid  epithelial  down- 
growths  (Fig.  34).      The  smaller  ones  are  lined  with  a  double  layer 


70  THE    PATHOLOGY   OF   THE    EYE 

of  epithelium,  the   inner   being   cylindrical,  with   many  goblet-cells. 

These   contain   coagula,  granular  debris,  and  leucocytes  with   badly 

staining  nuclei.  The  larger  ones  may  be 
several  millimetres  in  diameter,  and  are  then 

lined  with  flattened  epithelium,  and  are  often 

empty  or  contain  a  clear  fluid  (Fig.  35). 
The  cysts  are  usually  surrounded  by  an  in- 
flammatory thickening  of  the  fibrous  tissue, 
which  forms  a  capsule. 

The  crypts  and  crevices  in  the  tra- 
chomatous  conjunctiva  must  afford  an  ex- 
cellent site  for  the  materies  morbi,  and  add 
greatly  to  the  difficulty  of  eradicating  the 
disease. 

Changes  in  the  surrounding  conjunctiva. — 
These  vary  greatly  in  degree,  but  are  always 

Herbert,  T.  O.  S..  xix.      Origin  u  4-U          j-rr  r"i 

of  a  conjunctival  cyst  from  an  present,  trachoma  thus  differing  from  fol- 
epithelial  tubule.  A.  Epithelial  licular  conjunctivitis.  They  consist  chiefly 
lining.  B.  Collect-ion  of  cells,  in  wide-spread  infiltration  with  lympho- 
:?"«yubrdCcrin|Pi,ehdia,diM±g  cytes,  especially  of  the  adenoid  layer, 
of  a  large  cyst.  D.  Surface  epi-  accompanied  by  oedema.  Besides  lympho- 
thelium  (out  of  focus).  cytes,  plasma-cells,  mast-cells,  and  "half- 

moon  "  cells  (Leber)  are  found.  Plasma- 
cells  are  found  in  enormous  numbers  beneath  the  epithelium,  and 
even  in  the  discharge  (Mayou).  Mast-cells  were  found  particularly  in 
trachoma  by  Fuchs,  but  are  in  noway  specific  (v.  p.  56).  "  Half-moon  " 
cells  are  mononuclear  cells,  the  nucleus  of  which  is  pressed  to  one  side 
of  the  cell  and  is  half-moon  or  sickle-shaped.  The  neighbouring  proto- 
plasm is  more  deeply  stained,  the  remainder  very  faintly  stained.  The 
concavity  of  the  crescent  is  always  directed  towards  the  surface  of  the 
conjunctiva.  Polymorphonuclear  leucocytes  are  often  present  in 
numbers  in  the  adenoid  layer.  They  may  lead  to  the  formation  of 
deeply- staining  networks  like  those  described  by  Peters  (v.  p.  56). 

After  the  disappearance  of  the  oedema  new  vessels  appear  in  the 
papillae,  with  numerous  capillary  loops.  Fibrous  tissue  develops  along 
the  walls  and  contracts,  the  papillae  shrinking,  whilst  folds  long  remain 
to  mark  their  position. 

Cicatrisation. — Trachoma  invariably  ends  in  cicatrisation,  but  the 
method  whereby  this  takes  place  is  a  matter  of  dispute,  and  probably 
varies.  Most  commonly  it  is  by  absorption  of  the  contents  of  the 
follicle  and  proliferation  of  the  connective  tissue  of  the  conjunctiva ; 
there  is  little  evidence  that  the  elements  of  the  follicle  can  themselves 
form  fibrous  tissue  to  any  considerable  extent.  Less  frequently  the 
contents  of  the  follicles  are  expelled  into  the  conjunctival  sac,  and  the 
resulting  "  ulcer  "  or  wound  is  healed  by  cicatrisation.  Raehlmann, 
Addario,  and  others  attach  an  undue  importance  to  this  method. 

Resorption  can  apparently  occur  at  any  stage,  by  mere  retrogression, 
without  softening.  This  must  be  regarded  as  exceptional.  Usually 
degenerative  changes  occur  in  the  cells.  The  large  cells  necrose,  their 
nuclei  no  longer  staining,  the  cytoplasm  becoming  granular.  This 


THE    CONJUNCTIVA  71 

generally  begins  in  the  centre,  but  foci  may  be  dotted  about.  The  cells 
finally  break  down  into  a  granular  mass,  and  spaces  are  formed, 
separated  from  each  other  by  the  more  resistent  fibrous  tissue.  The 
blood-vessels  at  the  periphery  and  in  the  neighbouring  conjunctiva  are 
often  sclerosed,  with  thickened  homogeneous  walls,  and  finally  obliterated 
lumina  (Raehlmann).  This  process  may  be  the  cause  of  the  necrosis. 

Where  the  follicles  are  very  thickly  set  softening  may  lead  to  fusion, 
and  may  extend  to  the  adenoid  layer  and  epithelium  in  the  form  of 
fatty  or  hyaline  degeneration.  The  clinical  picture  is  then  charac- 
teristic, and  has  led  to  the  term  gelatinous  trachoma  (Stellwag).  The 
epithelium  then  often  gives  a  mahogany-brown  coloration  with  iodine, 


FIG.  35. — TRACHOMA,      x    34. 
From  a  specimen  by  Herbert.     Cysts  in  upper  palpebral  conjunctiva. 

but  it  is  probable  that  the  true  amyloid  degeneration  of  the  con- 
junctiva is  wholly  independent  of  trachoma  (Raehlmann,  Reymond, 
Kubli,  Vossius)  (v.  infra). 

It  is  probable  that  in  many  cases  the  process  of  resorption  is  slower, 
and  the  degenerative  changes  are  less  marked.  The  new  growth  of 
fibrous  tissue  is  then  the  more  prominent  feature,  and  the  process  is 
one  of  slow  induration  rather  than  softening.  In  rare  cases,  indeed, 
simple  absorption  with  a  minimum  of  scarring — though  always  some — 
may  occur  (Greeff). 

According  to  Raehlmann,  Addario,  and  others,  the  softening  generally 
involves  the  adenoid  layer,  which  shows  fatty  degeneration.  The 
epithelium  becomes  thinned  and  finally  broken  through,  and  the 
follicle  opens  on  to  the  surface.  The  contents  are  gradually  extruded, 
the  process  being  aided  by  movements  of  the  lids,  etc.  The  walls  then 
fall  together,  the  space  being  rapidly  filled  with  granulation  tissue, 


72  THE    PATHOLOGY   OF   THE    EYE 

which  finally  forms  a  compact  scar.  This  method  cannot  occur  in 
those  cases  in  which  a  complete  capsule  of  fibrous  tissue  is  gradually 
built  up,  and  is  probably  exceptional  in  all  cases. 

Addario  is  doubtless  right  in  deriving  the  new  fibrous  tissue  chiefly 
from  the  adventitia  of  the  blood-vessels  (cf.  "  Retina").1  It  accumu- 
lates at  the  periphery,  first  on  the  under  surface,  finally  encapsuling 
the  follicle.  Gradually  it  encroaches  more  and  more  upon  the  centre, 
the  specific  cells  disappearing  before  it.  These  are  at -last  almost  con- 
fined to  the  centre,  and  are  even  here  pervaded  by  bold  bands  of  fibrous 
tissue.  As  the  fibrous  tissue  contracts,  so  the  follicle  shrinks.  Most 
commonly  the  process  is  not  confined  to  the  follicles,  but  invades  the 
whole  neighbourhood  of  the  conjunctiva,  the  connective  tissue  proliferat- 
ing, contracting,  strangling  the  vessels,  and  eventuating  in  compact 
scar  tissue,  no  trace  of  follicles  being  finally  left. 

Changes  in  the  tarsus,  etc. — Histological  changes  in  the  tarsus  were 
first  described  by  Wolfring,  viz.  nests  of  lymphocytes  amongst  the 
fibres.  Raehlmann  considered  that  the  distortion  of  the  tarsus  was 
mainly  due  to  contraction  of  the  conjunctival  scar.  Most  authors,  e.g. 
Saemisch,  v.  Michel,  Fuchs,  Greeff,  etc.,  think  that  there  is  usually  a 
primary  affection  of  the  tarsus,  and  Raehlmann  now  admits  this  in 
some  cases.  The  tarsus  is  usually  bent  so  that  the  convex  surface  looks 
forwards.  This,  according  to  Raehlmann  and  Pick,  is  due  to  the 
thickness  and  contraction  of  the  conjunctival  fibrous  tissue  on  the 
inner  surface,  the  union  between  the  two  being  normally  very  firm. 
There  is  no  necessity  for  the  tarsus  itself  to  be  inflamed.  Sometimes 
the  fibrous  tissue  of  the  tarsus  contracts  pari  passu  with  the  scar  tissue, 
and  the  tarsus  then  shrinks  in  size  without  becoming  bent.  This 
occurs  particularly  in  the  severer  forms  of  trachoma,  e.  g.  gelatinous 
trachoma,  in  spite  of  the  extreme  swelling  of  the  lids  which  happens 
earlier  in  these  cases  (Raehlmann).  The  bending  is  most  marked 
when  the  middle  of  the  tarsus  is  softened  by  the  follicular  process,  the 
edges  remaining  firm.  Where  the  tarsus  atrophies  it  may,  like  the 
scar  itself,  be  replaced  by  a  loose  reticular  tissue  containing  fat. 

In  the  earlier  stages  it  is  the  rule  to  find  the  tarsus  invaded  by 
round-cells,  including  mast-cells,  which  find  their  way  along  the  blood- 
vessels and  lymph  spaces,  especially  in  the  neighbourhood  of  the  upper 
and  lower  arterial  arches. 

All  the  tarsal  glands  are  affected  by  the  process,  especially  the 
Meibomian  glands.  As  long  as  the  follicles  are  limited  to  the  fornices, 
the  Meibomian  secretion  is  not  altered.  When  they  invade  the  C. 
tarsi,  the  secretion  becomes  grumous  and  frothy.  The  bending  of  the 
lid  leads  to  ectasia  of  the  ducts,  whilst  the  acini  may  still  continue  to 
be  functional.  Later  the  acini  atrophy,  first  in  the  upper  lid,  being  to 
a  large  extent  strangled  by  the  overgrowth  of  bands  of  fibrous  tissue. 
Many  of  the  acini  degenerate  into  cystic  spaces,  lined  with  irregular 
cubical  epithelium.  The  irritation  sometimes  leads  to  the  formation 
of  groups  of  giant-cells  in  the  vicinity.  Other  acini  become  filled 
with  cells,  whilst  many  disappear  entirely  and  are  replaced  by  fatty 

1  PARSONS,  R.  L.  O.  H.  Rep.,  xv,  3,  1903. 


THE    CONJUNCTIVA  73 

connective  tissue.  The  follicles  in  rare  cases  invade  the  edge  of 
the  lid,  and  thus  lead  to  implication  of  Moll's  glands;  the  cysts  are  then 
more  frequently  quite  denuded  of  epithelium. 

Pick  showed  that  the  infiltration  of  the  conjunctiva  extends  deeply 
in  the  fornix,  where  the  submucous  tissue  is  loose ;  it  may  extend  as 
far  as  between  the  muscle  bundles.  Raehlmann  says  that  Krause's 
glands  are  often  colossally  hypertrophied,  the  hypertrophy  corre- 
sponding in  degree  with  the  atrophy  or  loss  of  function  of  the  Meibomian 
glands.  They  seem,  therefore,  to  act  in  some  degree  vicariously. 

Cicatrisation  leads  to  displacement  of  Krause's  glands,  so  that  they 
usually  come  to  lie  behind  the  middle  of  the  lid.  Infiltration  of 
Krause's  glands  may  also  occur,  probably  more  commonly,  followed 
by  partial  or  complete  atrophy  and  the  formation  of  cysts. 

VETSCH. — An  Account  of  the  Ophthalmia  which  has  appeared  in  England  since  the 
return  of  the  British  Army  from  Egypt,  London,  1807.  BENDZ. — Compte  rendu  du  Congres 
d'Opht.,  Paris,  1858.  WOLFRING. — A.  f.  O.,  xiv,  3,  1868.  BI.UMBERG. — A.  f.  O.,  xv,  i, 
1869.  LEBER. — A.  f.  O.,  xix,  2,  1873.  SAEMISCH.- — G.-S.,  iv,  1874.  BERLIN. — K.  M.  f.  A., 
xvi,  1878.  IWAXOFF. — B.  d.  o.  'G.,  1878.  JACOBSOX,  JR. — A.  f.  O.,  xxv,  2,  1879. 
SAEMISCH. — Bericht  d.  Ophth.  Congr.,  Amsterdam,  1879.  SATTLER. — B.  d.  o.  G.,  1881, 
1882.  XUEL. — Ann.  d'Oc.,  Ixxxviii,  1882.  MANDELSTAMM. — A.  f.  O.,  xxix,  i,  1883. 
RAEHLMANN. — A.  f.  O.,  xxix,  2,  1883.  BAUMGARTEX. — A.  f.  O.,  xxx,  i,  1884.  RAEHL- 
MANN.— A.  f.  O.,  xxxi,  2  and  3,  1885;  xxxiii,  2,  1887.  STADERINI. — Ann.  di  Ott., 
xvi,  1888.  RHEIN. — A.  f.  O.,  xxxiv,  3,  1888.  SCHMIDT-RIMPLER. — Internat.  Med.  Con- 
gress, Berlin,  1890.  REID. — T.  O.  S.,  x,  1890.  MOAURO. — Ann.  di  Ott.,  xix,  1891.  MUTER- 
MILCH. — Ann.  d'Oc.,  1891,  1892,  1893.  GREEFF. — A.  f.  A.,  xxiv,  1892;  *in  Orth,  Lehr- 
buch,  1902.  OMELTSCHENKO. — C.  f.  A.,  xviii,  1894.  RIDLEY. — T.  O.  S.,  xiv,  1894. 
STEPHEXSOX — Epidemic  Ophthalmia,  Edinburgh,  1895.  LEBER. — B.  d.  o.  G.,  1896. 
*ViLLARD. — Anat.  path,  de  la  Conj.  granuleuse,  Paris,  1896.  PICK. — A.  f.  O.,  xliv,  3, 
1897.  ALT. — Am.  Jl.  of  Ophth.,  xv,  1898.  *Juxius. — Z.  f.  A.,  i,  1899  ;  viii,  Erganzungsheft, 
1902.  HERBERT. — T.  O.  S.,  xix,  1899;  Jl.  of  Path.,  1900.  ADDARIO. — A.  f.  A.,  xli,  i,  1900. 
RAEHLMANN. — A.  f.  A.,  xlvi,  3,  1902.  MAYOU. — Personal  communication.  AXENFELD. — 
Trachom,  Freiburg,  1902.  BOLDT. — Das  Trachom,  Berlin,  1903  (translation  in  preparation, 
by  Parsons  and  Snowball). 

The  Bacteriology  of  Trachoma. — There  can  be  no  doubt  that  trachoma 
is  contagious,  a  fact  which  was  proved  by  Piringer ;  the  organism,  how- 
ever, has  as  yet  escaped  demonstration. 

Hirschberg  and  Krause  (1881)  obtained  bacilli  from  "acute" 
trachoma,  but  failed  to  find  them  in  chronic  cases.  Koch  (1883) 
regarded  the  bacillus  now  known  as  the  Koch-Weeks  bacillus  as  a 
concomitant  cause  with  the  gonococcus,  but  erroneously. 

Sattler  (1881)  described  a  diplococcus  as  the  cause.  It  resembled 
the  gonococcus,  but  was  smaller.  Other  diplococci  have  been  described 
by  v.  Michel,  Schmidt,  Kucharski,  Raehlmann,  Poncet,  Staderini,  etc. 
In  most  cases  they  stained  by  Gram's  method,  and  in  many  inocula- 
tion was  successful.  None,  however,  have  withstood  the  test  of 
criticism. 

Shongolowicz  (1890)  found  a  bacillus  of  extremely  slow  growth,\vhich 
gave  positive  results  when  inoculated  into  animals.  L.  Miiller  (1897) 
described  a  bacillus  similar  to  the  influenza  bacillus,  but  difficult  to 
distinguish  from  the  Koch-Weeks  bacillus.  Morphologically  and  by 
culture  the  differences  are  minimal,  and  most  critics  will  agree  with 
Axenfeld  in  considering  them  identical. 

Little  more  than   an   enumeration  of  some  of  the  wilder  flights  of 


74  THE    PATHOLOGY   OF   THE    EYE 

other  investigators  need  be  given.  Noiszewski  found  a  microsporon 
similar  to  the  Microsporon  furfur  (Kaposi)  of  pityriasis  versicolor. 
Cazalis  found  the  Streptothrix  Foersteri.  Burchardt  confounded  goblet- 
cells  with  coccidia,  as  did  also  Ridley,  though  more  guardedly.  Elze 
wrote  a  treatise  on  plasmodia  in  trachoma,  and  described  sixty-two 
evolution  forms. 

More  interesting  are  the  observations  of  Krtidener.  The  presence 
of  pigment  granules  in  trachoma  follicles  has  long  been  known.  In 
1881  Leber  stated  that  he  had  observed  swarming  movements — like 
those  of  swarm-spores — in  the  superficial  cells  of  fresh  trachoma  tissue. 
Kriidener  observed  the  pigment  granules  under  an  oil  immersion,  and 
also  saw  movements  like  those  of  ciliated  epithelium.  He  called  the 
granules  swarm-cells  ("  Wimmelzellen ").  Jt  is  suggestive  that  the 
granules  or  cells  are  commonest  when  there  is  a  large  amount  of 
disintegration  products.  The  appearances  are  probably  due  to 
Brownian  movements. 

The  failure  to  find  a  specific  organism  has  led  some  observers  to 
doubt  the  existence  of  any  (Mutermilch,  Cuenod,  Gunning)  ;  others 
have  thought  that  many  organisms  can  cause  the  disease  in  predisposed 
individuals  (Cazalis)  ;  whilst  others  have  had  recourse  to  a  last  resource 
— mixed  infection  (Lawson  and  others). 

PIRINGER. — Die  Blennorrhoe  am  Menschenauge,  Graz,  1840.  HIRSCHBERG  AND  KRAUSE. 
— C.  f.  A.,  v,  1881.  KOCH.— Wiener  med.  Woch.,  1883.  SATTLER.— B.  d.  o.  G.,  1881,  1882. 
v.  MICHEL. — A.  f.  A.,  xvi,  1886;  Der  Mikroorg.  d.  sog.  agyp.  Augenentziindung,  Wies- 
baden, 1887.  SCHMIDT. — Dissert.,  St.  Petersburg,  1887.  KUCHARSKI. — C.  f.  A.,  xi,  1887. 
STADERINI. — Ann.  di  Ott.,  xvi,  1887.  SHONGOLOWICZ. — St.  Petersb.  med.  Woch.,  1890. 
L.  MULLER. — Wiener  klin.  Woch.,  1897;  A.  f.  A.,  xl,  1899;  A.  f.  O.,  Ivii,  i,  1903. 
NOISZEWSKI. — C.f.  A.,  xv,  1891.  CAZALIS. — These,  Montpellier,  1895.  BURCHARDT. — C.  f.  A., 
xxi,  1897.  RIDLEY. — T.  O.  S.,  xiv,  1894.  ELZE. — Plasmodienbefunde  bei  Trachom, 
Zwickau,  1897.  LEBER. — B.  d.  o.  G.,  1881.  KRUDENER. — St.  Petersb.  med.  Woch.,  1895. 
LAWSON. — R.  L.  O.  H.  Rep.,  xiv,  3,  1897. 

FOLLICULAR   CONJUNCTIVITIS 

We  have  stated  that  follicular  conjunctivitis  is  regarded  by  some  as 
a  precursor  of  trachoma,  the  two  diseases  being  in  reality  one.  This 
position  cannot  be  maintained.  It  is  true  that  microscopically  the 
follicle  and  the  early  trachoma  granulation  are  essentially  identical,  so 
that  there  is  little  to  add  as  to  the  histology  (Figs.  36,  37).  Mayou  finds 
fewer  plasma-cells  in  the  subepithelial  tissue  in  follicular  conjunctivitis  ; 
these  are  present,  on  the  other  hand,  in  the  follicles,  whilst  they  are 
absent  here  in  trachoma.  The  discharge  contains  fewer  plasma-cells 
than  in  trachoma.  Whilst  the  latter  is  always  accompanied  by  diffuse 
inflammation  and  infiltration,  these  are  often  absent  in  the  former.  It 
is  therefore  not,  properly  speaking,  a  conjunctivitis,  but  merely  a 
symptom  indicative  of  many  diverse  conditions. 

Follicles  are  normally  present  in  many  animals,  and  may  be  best 
demonstrated  by  treatment  with  0*5  per  cent.  HC1,  followed  by  alum 
carmin  (Leber).  This  treatment  fails  to  show  them  in  the  normal 
human  conjunctiva. 

They  are  frequently  found  in  school  children,  especially  weakly 
ones,  suffering  from  anaemia,  tubercle,  etc. ;  they  are  also  often 


THE    CONJUNCTIVA 


75 


associated  with  hyperrnetropia.     Many  of  the   children   affected  also 
suffer  from  adenoid  vegetations  in  the  throat,  a  pathologically  allied 


FIG.  36. — FOLLICULAR  CONJUNCTIVITIS,      x   120. 
From  a  specimen  by  Herbert. 

condition.  They  occur  in  many  institutions,  asylums,  etc.,  and  in 
those  living  under  bad  hygienic  conditions.  Noxious  matter  in  the 
air,  and  very  various  thermal,  chemical,  and  bacterial  irritants  all 


FIG.  37. — FOLLICULAR  CONJUNCTIVITIS. 

Herbert,  T.  O.  S.,  xix.  Spreading  margin  of  a  follicle,  showing  columns  of 
cells  grouped  in  lymph  spaces,  c.  Epithelium.  B.  Layers  of  large  plasma-cells. 
A.  The  cells  of  the  follicle  slightly  out  of  focus;  they  should  be  closely  packed. 

seem  able  to  cause  their  development.      They  are  familiar  in  cases  of 
atropine  irritation,  less  commonly  with  eserine,  and  rarely  with  zinc 


76  THE    PATHOLOGY   OF   THE    EYE 

lotions ;  rarely  also  in  cases  of  syphilis  and  tuberculosis  of  the 
conjunctiva. 

On  the  other  hand,  they  never  develop  as  the  result  of  gonorrhceal  or 
diphtherial  conjunctivitis,  nor  after  simple  chronic  catarrh,  even  if 
prolonged. 

The  facts  that  there  may  be  no  conjunctivitis,  that  the  follicles 
disappear  without  cicatrisation,  and  that  they  occur  in  districts  in 
which  trachoma  is  unknown,  would  seem  to  be  fatal  to  the  Unitarian 
theory. 


PHLYCTENULAR   CONJUNCTIVITIS 

Phlyctenular  or  eczematous  conjunctivitis  has  not  been  fully  in- 
vestigated histologically,  owing  to  the  difficulty  of  obtaining  material. 
Excised  phlyctenules  show  little  but  intensely  inflamed  and  infiltrated 


FIG.  38. — CONJUNCTIVITIS,      x  60. 

The  specimen  was  taken  from  a  typical  case  of  episcleritis  in  an  elderly 
woman.  It  cannot  be  regarded  as  typical  pathologically,  but  resembles  the  condi- 
tion found  in  phlyctenular  conjunctivitis.  There  is  a  conical  area  of  round-celled 
infiltration,  which  also  involves  the  epithelium,  though  there  is  no  actual  ulceration. 

conjunctiva,  with  or  without  ulceration  and  loss  of  epithelium  (cf.  Fig. 
38). 

Iwanoff  (1869)  first  investigated  the  subject,  and  his  classical 
description  and  figures  are  familiar  from  the  ordinary  text-books. 
More  recently  the  subject  has  received  attention  from  Leber,  Winter- 
steiner,  v.  Michel,  etc.  (see  also  "  Phlyctenular  Keratitis"). 

Leber  and  Wintersteiner  invariably  found  nodules  of  round-celled 
infiltration.  The  epithelium  is  raised,  then  thinned,  and  finally  broken 


THE    CONJUNCTIVA  77 

on  the  surface.  The  infiltrating  cells  are  principally  polymorpho- 
nuclear  leucocytes,  which  are  small  at  the  periphery,  larger  towards  the 
centre,  and  flattened  near  the  surface,  where  the  nuclei  are  smaller  and 
stain  badly,  probably  owing  to  commencing  necrosis.  Leber  found 
giant-cells  in  three  cases  out  of  four,  not  always  in  the  nodules,  but  also 
under  the  epithelium.  Wintersteiner  found  them  only  at  the  periphery 
of  ulcers.  There  is  never  caseation,  and  the  appearances,  though  they 
offer  some  similarity  to  tubercles,  are  not  identical.  The  endothelium 
of  the  vessels  is  swollen,  shows  mitoses,  and  may  be  fused  into  giant- 
cells. 

v.  Michel  describes  the  formation  of  vesicles  and  pustules,  which 
have  not  been  observed  by  others.  In  the  first  stage  there  is  infiltra- 
tion with  uni-  and  multi-nuclear  leucocytes,  which  invade  the  intact 
epithelium.  The  lymphatics  are  dilated,  and  the  blood-vessels  full  of 
corpuscles  and  surrounded  by  a  zone  of  lymphocytes  ;  thromboses  and 
haemorrhages  may  occur.  Later,  the  surface  necroses  and  an  ulcer 
is  formed ;  or  the  epithelial  layers  become  separated  by  a  fibrinous 
exudate  containing  leucocytes  and  swollen  epithelial  cells,  and  minute 
vesicles  are  formed.  The  subepithelial  tissues  are  also  cedematous, 
and  contain  fibrinous  coagulum.  An  ulcer  is  also  formed  eventually, 
the  floor  of  which  is  covered  with  granulation  tissue.  Healing  takes 
place  after  the  casting  off  of  the  necrosed  cells  by  the  formation  of 
layers  of  closely  packed  spindle-shaped  cells,  which  are  covered  by 
epithelium  growing  in  from  the  edges. 

The  term  "  phlyctenule"  is  only  justified  if  vesicles  are  formed,  as 
held  by  v.  Michel.  It  may,  however,  be  retained  until  accurate 
knowledge  of  the  pathology  and  pathological  anatomy  of  the  disease 
is  obtained.  When  vesicles  definitely  occur,  as  in  herpes,  the  walls 
fall  together  after  they  burst ;  whereas  a  phlyctenule  is  always  solid, 
and  forms  a  crateriform  ulcer  (Sattler).  The  term  "  eczema "  is 
equally  open  to  objection,  since  the  condition  is  essentially  a  scrofulous 
one  (Axenfeld),  and  the  accompanying  eczema  of  the  lids  is  secondary; 
moreover  there  is  no  uniformity  as  to  the  pathology  of  eczema. 

IWANOFF. — B.  d.  o.  G.,  1869.  v.  MICHEL. — Z.  f.  A.,  iv,  1900.  LEBER,  WINTERSTEINER. 
— B.  d.  o.  G.,  1901.  AXENFELD,  LEBER,  WAGENMANN,  SATTLER,  etc. — B.  d.  o.  G.,  1897. 

Bacteriology. — Gifford  (1886)  first  investigated  phlyctenular  conjunc- 
tivitis for  bacteria  ;  he  found  Staphylococcus  pyogenes  albus  and  aureus  in 
twenty-six  cases  out  of  twenty-eight.  Burchardt  (1887)  found  Micrococcus 
flavus  desidem  (Fliigge),  and  produced  phlyctenule-like  infiltrations  in 
rabbits'  corneas  with  it.  In  a  later  work  (1893)  he  obtained  staphy- 
lococci  most  frequently ;  often  they  could  be  demonstrated  only  by 
culture.  Leber  (1888)  failed  to  produce  phlyctenules  in  man  by 
staphylococci ;  Burchardt's  experiments  on  rabbits  prove  nothing. 
Most  later  observers  have  found  staphylococci  (Gallenga,-  Morax, 
Straub,  Bach),  which  may  be  accessory,  though  not  causal,  but  are 
more  likely  to  be  mere  contaminations. 

The  observations  of  Baas  (v.  "  Phlyctenular  Keratitis  ")  tend  to  show 
that  the  stimulus  to  the  formation  of  phlyctenules  is  endogenous  and 
not  ectogenous.  Leber  (1901)  was  unable  to  find  tubercle  bacilli,  and 


78  THE    PATHOLOGY   OF   THE    EYE 

he  showed  that  the  skin  affection  can  be  induced  by  cocci  cultivated 
from  the  eye  without  skin  abrasion,  whilst  the  same  cocci  are  inactive 
in  the  conjunctiva  even  after  abrasion  of  the  epithelium.  It  is  possible 
that,  the  conjunctivitis  is  due  to  the  action  of  tubercle  toxins.  'Leber 
has  observed  the  effects  of  the  injection  of  sterilised  dead  tubercle 
bacilli  into  the  cornea.  The  bacilli  were  rapidly  taken  up  by  leucocytes. 
When  the  injection  was  made  in  the  centre  of  the  cornea  a  dense 
cellular  infiltration  of  the  wound,  with  a  greyish  zone  around  it,  was  the 
result.  This  was  followed  by  a  small  loss  of  substance,  which  was 
gradually  restored  with  more  or  less  vascularisation.  Recovery,  how- 
ever, was  followed  by  fresh  outbreaks  of  inflammation  and  punctiform 
projecting  infiltrates.  Experiments  with  sterilised  bacilli  injected  into 
the  blood-vessels  were  unsuccessful. 

GIFFORD. — A.  of  O.,  xv,  1886.  BURCHARDT. — C.  f.  A.,  xl,  1887  ;  Dermatol.  Zeitschrift, 
i,  1893-4.  LEBER. — VII  internat.  Congress  zu  Heidelberg,  1888;  B.  d.  o.  G.,  1897,  1901. 
GALLENGA. — Ateneo  medico  Parmense,  1889.  STRAUB. — A.  f.  A.,  xxv,  1892 ;  Nederl. 
Oogheelkund.  Bydragen,  1896.  AXENFELD. — Berlin,  klin.  Woch.,  1897;  B.  d.  o.  G.,  1897. 
MORAX. — These  de  Paris,  1899;  Ann.  d'Oc.,  cxvii,  1897.  BACH. — A.  f.  O.,  xli,  i,  1895; 
Z.  f.  A.,  i,  1897;  iii,  1898;  Vossius'  Sammlung,  iii,  i,  1899.  MEIJERS. — Dissert.,  Jena, 
1898.  HERTEL. — A.  f.  O.,  xlvi,  3,  1898.  SCHOLZ. — Deutsche  med.  Woch.,  1900;  Deutsche 
Klinik,  1903. 


SYPHILIS 

Primary  chancres  occur  rarely  upon  the  conjunctiva,  especially  at 
the  lid  margins  and  the  fornix.  Hitschmann  examined  one  from  the 
fornix  microscopically.  He  found  the  epithelium  thickened,  with 
"  colloid  "  degeneration  in  places.  Below  this  was  a  slightly  infiltrated 
zone  of  connective  tissue,  followed  by  a  densely  infiltrated  part.  The 
infiltration  followed  the  vessels,  and  consisted  of  round-cells  with  a  few 
mast-cells.  The  vessels  were  thickened  and  compressed.  Nothing 
very  characteristic  was  made  out,  and  the  case  is  open  to  doubt  on 
diagnostic  grounds.  Gummata  also  occur. 

Syphilitic  inflammations  tend  to  show  more  degenerative  changes 
and  necrosis  than  other  types  ;  this  is  due  to  the  more  marked  endo- 
and  peri-vascular  changes  which  are  found  ;  there  is  also  more  prolifera- 
tion of  granulation  tissue  than  usual. 

Reiner,  Elschnig,  and  Fialho  found  diffuse  changes  in  the  con- 
junctiva in  their  cases.  They  are  probably  allied  to  those  found  in 
annular  scleritis  (q.  v.).  There  were  the  usual  signs  of  inflammation, 
with  polymorphonuclear  cells,  plasma-cells,  and  mast-cells.  There 
were  no  giant-cells  or  necrosis.  In  Fialho's  case  there  were  extensive 
changes  in  other  parts  of  the  eye,  with  giant-cells. 

There  are  some  cases  of  conjunctivitis  with  localised  redness  and 
swelling  in  which  typical  giant-cell  systems  are  found,  such  as  are 
usually  associated  with  tubercle.  Some  of  these  clear  up  rapidly  with 
mercury  and  potassium  iodide.  One  such  is  described  fully  by  Pepp- 
muller,  and  I  have  seen  another  almost  identical  with  this.  I  was 
unable  to  find  tubercle  bacilli,  and  Peppmuller  failed  after  prolonged 
search  ;  eventually,  however,  they  were  found  in  his  case. 


THE    CONJUNCTIVA 


79 


HITSCHMANN. — Wien.  klin.  Woch.,  1897.  REINER. — B.  z.  A.,  xxiii,  1898.  ELSCHNIG. 
— K.  M.  f.  A.,  xxxv,  1897.  FIALHO.— A.  f.  O.,  lii,  3,  1901.  PEPPMULLER. — A.  f.  O.,  xlix,  2, 
1899  ;  1,  3,  1900. 


TUBERCLE 

Tubercle  of  the  conjunctiva  is  probably  not  so  rare  as  has  been 
thought  (i  in  6000  ophthalmic  cases,  Hirschberg,  1881 ;  i  in  30,000, 
Mules,  1885 ;  i  in  2700,  Eyre,  1900)  (Figs.  39 — 45). 

Sattler  distinguished  four  groups  of  cases,  which  have  been  modified 
by  Eyre  as  follows  : 

1.  Characterised  by  the   presence  of  one  or   more  small  miliary 
ulcers,  which  usually  caseate,  and  may  or  may  not  coalesce ;    these 
generally  attack  the  palpebral  in  preference  to  the  bulbar  conjunctiva. 

Scrapings  from  these  ulcers  used  to  prepare  cover-glass  films,  and 
suitably  stained,  say  by  the 
Ziehl-Neelsen  method,  generally 
show  numerous  small  groups  or 
bunches  of  bacilli  indistinguish- 
able morphologically  in  their 
tinctorial  reactions  from  the 
tubercle  bacillus. 

2.  Characterised  by  the  pre- 
sence   of    greyish    or    yellowish 
subconjunctival  nodules,  varying 
in    size,   but   rarely    larger  than 
a  hemp-seed — resembling  some- 
what the  sago  granules  of  acute 
trachoma    when     grey,    or    the 

tubercles  met  with  in  the  lungs      FlG  39._TuBERCLE  OF  THE  CONJUNCTIVA. 
of  acute  miliary  tuberculosis  when      After  EyrC)  T  o  s>  xvii;  pl  L     Case  x 

yellow.  These  are  regarded  by  Group  I :  showing  granulations  on  the  temporal 
Eyre  as  the  initial  Stage  of  the  side  of  the  bulbar  conjunctiva,  with  central 

next  type  ;  these  small  tubercles,  caseous  mass- 
increasing  in  size  by  proliferation 

of  the  small  round-celled  exudation  which  encircles  the  giant-cell 
systems,  absorb  their  conjunctival  covering.  The  continued  action  of 
the  central  irritant  is  responded  to  by  a  like  activity  of  the  cell  elements, 
and  as  the  growth  tends  to  take  place  along  the  lines  of  least  resistance, 
the  fungating  granulations  of  the  third  group  are  the  inevitable 
result. 

Sections  of  the  small  miliary  tubercles  show  well-defined  giant-cell 
systems  (Fig.  43)  ;  and  scattered  here  and  there,  without  any  definite 
arrangement  or  relationship  to  these  giant-cells,  small  groups  of  tubercle 
bacilli,  seldom  numbering  more  than  ten  to  twelve  individuals,  can 
usually  be  demonstrated. 

3.  Characterised  by  the  presence  of  florid  hypertrophied  papillae 
and  rounded,   flattened  outgrowths  of  granulation  tissue,  sometimes 
derived  from  the  tarsal  conjunctiva,  but  usually  springing  from  the 
fornices  (resembling  in  many  respects  the  velvety  granulations  met 


So 


THE   PATHOLOGY    OF   THE    EYE 


or    less    superficial 


FIG.  40. — TUBERCLE  OF  THE  CONJUNCTIVA. 
After  Eyre.     Case  3,  Group  II:  showing 
subconjujictival    nodules    on    the    palpebral 
conjunctiva.     The  lid  has  been  everted. 


with  in  tubercular  arthritis),  and  associated  with  oedema  and  thickening 
of  the  lids. 

Sections  of  the  hypertrophied  papillae  and  flattened  granulations 
as  a  rule  show  nothing  but  masses  of  small  round-cells  with  occa- 
sional large  polygonal  cells,  but 
no  definite  giant-cell  systems. 
Tubercle  bacilli  are  usually  scat- 
tered, but  very  sparsely,  throughout 
the  tissue,  and  it  generally  happens 
that  they  are  missed.  In  any  case 
one  must  be  prepared  to  examine 
scores  of  sections,  and  even  then 
have  to  record  a  negative  result. 

4.  Characterised  by  the  presence 
of  numerous  pedunculated  cocks- 
comb excrescences  on  the  fornices, 
of  a  jelly-like  consistence,  and  often 
showing  more 
ulceration. 

Sections  of  the  jelly-like  masses 
occurring  in  this  group  consist  of 
masses  of  small  round-cells,  but 
show  in  addition  a  large  proportion 
of  newly  formed  blood-vessels  of  the  embryonic  type.  It  is  difficult 
to  demonstrate  the  tubercle  bacillus  in  the  sections. 

5.   Characterised  by    the    presence    of    a    distinctly    pedunculated 

tumour  (very  rarely  more  than  one 
may  be  present),  having  the  macro- 
scopic appearances  of  a  papilloma  or 
fibroma  of  the  tarsal  conjunctiva. 

Sections  of  the  tumour  generally 
show  a  stroma  of  fairly  dense  con- 
nective tissue  enclosing  a  mass  of 
round-cells,  with  here  and  there 
giant-cell  systems ;  and  in  these 
systems,  or  in  close  proximity  to 
them,  tubercle  bacilli  may  be  found, 
either  isolated  or  in  small  bunches 
of  five  to  ten  individuals. 

The  first   three    groups  agree  in 
the  main  with  Sattler's  ;  his  fourth 
group  is  lupus,  characterised  by  ulcers 
with  steep  swollen  edges  surrounded 
After  Eyre.   Case  4,  Group  III :  showing   by  very  vascular  granulation  tissue, 
prominent  granulations.    Both  lids  have   Other  cases  have  been  described  in 

been  everted.  1-1,1  •  •       ,    • 

which  there  was  extensive  cicatrisa- 
tion and  shrinking,  suggestive  of  pemphigus  (Burnett,  Reimar). 

The  characteristic  features  described  by  Sattler  and  Eyre  are  some- 
times mixed  up,  so  that  no  hard  and  fast  line  can  be  drawn  between 
the  groups.  Thus  I  have  seen  a  typical  "  cockscomb  "  excrescence 


FIG.  41. — TUBERCLE  OF  THE  CON- 
JUNCTIVA. 


THE    CONJUNCTIVA 


81 


along  the  whole  lower  fornix  in  which  there  were  crowds  of  well-defined 
giant-cell  systems.  Bacilli  are  often  few  and  far  between  in  the 
sections,  and  demonstration  of  them  is  a  laborious  process.  The  only 
absolutely  reliable  test  is  inoculation  into  a  rabbit's  anterior  chamber, 
which  is  followed  in  a  few  weeks  by  tubercular  nodules  upon  the  iris, 
and  commonly  general  dissemination  arid  death. 

Birch-Hirschfeld  carefully  examined  three  cases  belonging  to 
Sattler's  first,  second,  and  fourth  (lupus)  groups.  The  trachoma-like 
case  is  interesting  in  that  there  is  reason  to  think  that  it  was  derived 
from  a  cow  which  was  subsequently  proved  to  have  "  Perlsucht  ;  "  if 
so,  this  is  proof  of  the  identity  of  human  and  bovine  tubercle,  as 
against  Koch's  theory.  Many  cases  of  this  group  are  undoubtedly 
treated  as  trachoma,  their  true  aetiology  never  being  recognised.  The 
lupous  cases  are  doubtless  due  to  transference  of  infection,  lupus  of  the 
face,  nose,  or  larynx  being  usual 
concomitants  (Rhein,  Bach, 
Denig,  Grunert,  Birch-Hirsch- 
feld). Pannus  of  the  cornea 
may  occur  in  several  of  the 
groups,  and  adds  much  to  the 
difficulty  of  diagnosis  in  the 
trachoma-like  cases.  Uhthoff 
has  recorded  a  case  of  the 
second  group  following  tuber- 
culosis of  the  lacrymal  sac. 

Zimmermann  has  published 
a  typical  case  of  Eyre's  fifth 
group,  in  which  an  apparently 
simple  polypus,  with  a  long 
pedicle,  was  made  up  of  tuber- 
cular tissue  and  contained 
bacilli. 

The  reason  why  tubercle 
should  assume  such  protean 
forms  in  the  conjunctiva  is 

probably  the  very  variable  virulence  of  the  tubercle  bacillus,  and  also 
the  condition  of  the  individual  and  the  local  disposition  of  the  con- 
junctiva. The  first  factor  is  proved  by  the  great  differences  obtained 
in  inoculation  experiments.  Valude's  experiments  have  shown  that 
injury  of  the  conjunctiva  greatly  increases  the  risk  of  infection,  and 
these  results  are  supported  by  Fuchs.  Doubtless  phlyctenular 
ophthalmia  may  run  a  normal  course  in  eyes  previously  affected  with 
tuberculosis  (Birch-Hirschfeld). 

The  question  whether  the  conjunctival  affection  is  primary  or 
secondary  is  difficult  to  answer  in  many  cases.  In  the  lupous  cases  it  is 
doubtless  usually  secondary,  but  in  many  of  the  other  cases  reported  the 
patients  have  been  quite  healthy,  or  at  any  rate  suffering  from  no  demon- 
strable tubercular  affection.  Eyre  regards  the  cases  of  his  Groups  I,  II, 
and  V  as  invariably  primary.  Benson's  and  Griffith's  cases  of  "primary  ' 
lupus  were  recorded  before  accurate  classification  was  adopted. 

6 


FIG.  42. — TUBERCLE  OF  THE  CONJUNCTIVA. 

After  Eyre,  Case  7,  Group  V  :  showing  poly- 
poid tumour  springing  from  the  conjunctiva  of 
the  lower  lid. 


FIG.  43- — TUBERCLE  OF  THE  CONJUNCTIVA,      x   120. 

From  an  adult.  The  whole  of  the  inner  and  upper  parts  of  the  conjunctiva 
were  swollen  and  congested.  No  bacilli  were  found.  The  condition  improved 
on  general  treatment  with  mercury  and  potassium  iodide.  The  section  shows  a 
typical  giant-cell  system,  the  group  of  Langhans'  giant-cells  being  surrounded 
by  an  inner  zone  of  epithelioid  cells  and  an  outer  zone  of  lymphocytes. 


FIG.  44. — TUBERCLE  OF  THE  CONJUNCTIVA,     x  75. 

The  diagnosis  is  not  certain  in  this  case.  It  is  probably  a  tubercle  undergoing 
involution.  From  a  girl  set.  8.  Ocular  condition  of  twelve  months'  duration, 
starting  simultaneously  with  cervical  adenitis.  Mother,  brother,  and  sister  died  of 
tubercle.  R.  eye  :  chain  of  four  nodules  in  lower  fornix,  outermost  breaking  down. 
L.  eye  :  marginal  phlyctenule  below.  The  nodule  consists  of  epithelioid  cells,  sur- 
rounded and  infiltrated  with  lymphocytes  and  a  few  polymorphonuclear  leucocytes. 
The  fibrous  tissue  at  the  periphery  is  increased. 


THE    CONJUNCTIVA  83 

Eyre  and  others  have  stated  that  the  disease  shows  no  spontaneous 
tendency  to  recovery.  At  the  same  time  Homer,  Fuchs,  Reimar,  and 
others,  including  Eyre  himself,  have  obtained  good  results  by  mild 
treatment,  c.  g.  iodoform.  Nearly  all  authors,  however,  agree  that 
radical  treatment  by  knife  and  cautery  is  indicated  in  order  to  prevent 
general  tuberculosis.  The  relative  virulence  of  the  bacilli  and  the 
reaction  of  the  patient's  tissues  are  very  variable  factors,  and  where 
the  former  is  weak  and  the  latter  strong,  as  exemplified  by  energetic 
proliferation,  the  better  is  the  prognosis,  and  that  in  greatest  degree 
when  bacilli  are  difficult  to  find  and  inoculation  experiments  have  a 
long  incubation  period. 

The  pre-auricular  gland  of  the  same  side  as  the  affected  eye  is 


FIG.  45. — TUBERCLE  OF  THE  CONJUNCTIVA,      x  55. 

From  a  specimen  by  Stock  (Freiburg-i.-B.).  The  black  patches  are  due  to 
dirt,  the  specimen  having  been  removed  post  mortem.  On  the  extreme  left  is  a 
typical  giant-cell  system ;  on  the  extreme  right  below  is  a  typical  follicle.  The 
combination  is  unusual. 

usually  infected  early,  and  then  the  next  glands  in  the  series,  viz. 
those  below  the  angle  of  the  jaw.  This  symptom  is  not  infrequently 
absent,  and  is  only  of  diagnostic  importance  when  present. 

Proof  of  general  dissemination  from  a  primary  conjunctival  lesion 
is  yet  wanting. 

*£YRE. — T.  O.  S.,  xvii,  1897  (with  Bibliography) ;  A.  of  O.,  xxix,  1900.  SATTLER. — 
B.  d.  o.  G.,  1891.  KNAPP. — A.  of  O.,  xix,  1890.  *BURNETT. — A.  of  O.,  xix,  1890.  VALUDE, 
FUCHS. — B.  d.  o.  G.,  1887.  BACH. — A.  f.  A.,  xxviii,  1894.  DENIG.— A.  f.  A.,  xxxi,  1895. 
CHENEY. — T.  Amer.  O.  S.,  1896.  GRUNERT. — A.  f.  A.,  xxxiv,  1897.  HEINERSDORF. — 
K.  M.  f.  A.,  xxxv,  1898.  *BIRCH-HIRSCHFELD. — K.  M.  f.  A.,  xxxvii,  1900  (Bibliography). 
REIMAR. — K.  M.  f.  A.,  xxxvii,  1900.  CARGILL,  JESSOP. — T.  O.  S.,  xx,  1900.  UHTHOFF. — 
Berliner  klin.  Woch.,  1900.  STOCK. — K.  M.  f.  A.,  xli,  Beilageheft,  1903. 


84  THE    PATHOLOGY    OF   THE    EYE 


LEPROSY 

The  conjunctiva  is  most  commonly  affected  by  continuity  at  the 
lid  margins,  and  after  this  most  frequently  at  the  limbus. 

In  the  C.  tarsi  there  is  papillary  hypertrophy,  consisting  of  typical 
leprous  granulations  covered  by  flattened  epithelium,  which  is  often 
horny.  There  are  no  cylindrical  cells.  The  Meibomian  glands  rarely 
show  degeneration,  though  they  may  be  surrounded  by  crowds  of 
bacilli,  and  invaded  by  a  few. 

At  the  limbus  there  are  the  usual  granulations,  which  seldom  ex- 
tend into  the  sclera  until  late  in  the  disease.  They  cannot  be  dis- 
tinguished as  leprous  from  their  external  appearances,  but  only  by  the 
clinical  condition,  leprosy  of  the  eye  being  always  a  secondary  invasion, 
and  by  the  demonstration  of  the  bacilli. 

(For  BIBLIOGRAPHY,  see  "  Lids,"  "  Cornea.") 


OPHTHALMIA  NODOSA. 

The  essential  feature  of  ophthalmia  nodosa  is  a  nodular  conjunc- 
tivitis, not  unlike  tubercle  of  the  conjunctiva  (pseudo-tubercular  conjunc- 
tivitis), but  accompanied  by  acute  exacerbations.  The  first  case  was 
brought  forward  by  Pagenstecher  (1883),  and  he  was  followed  by  Baas 
(1888),  Weiss  (1889),  Wagenmann  (1890),  Kriiger  (1891-2),  Becker 
(1892),  Hillemanns  (1894),  Lawford  (1895),  etc. 

The  condition  is  caused  by  the  irritation  of  the  hairs  of  certain 
species  of  caterpillar — Lasiocampa  or  Bombyx  (B.  rubi,  B.  pini), 
Liparis  (L.  monacha,  L.  dispar),  etc.  Other  species,  e.g.  Cnethocampa 
(C.  processioned),  also  cause  conjunctival  irritation,  but  it  rarely 
becomes  so  severe  as  with  the  other  species,  nor  are  the  deeper  parts 
of  the  eye  (iris,  etc.)  affected  (Baas,  Wagenmann).  The  disease 
naturally  commences  only  during  the  period  of  active  life  of  the  cater- 
pillars, viz.  August,  September,  October.  One  case  is  said  to  have 
occurred  in  June  (Weiss). 

The  nodules  are  found  in  the  conjunctiva,  episclera,  and  iris,  the 
favourite  situation  being  the  ocular  conjunctiva  between  the  lower 
border  of  the  cornea  and  the  fornix ;  but  they  are  also  found  in  the 
palpebral  conjunctiva,  the  retrotarsal  folds,  and  the  deeper  tissues. 
They  are  multiple,  varying  from  three  to  twenty-six,  round  or  oval,  i  to 
2  mm.  in  diameter,  flattened,  grey  or  yellowish,  semi-translucent.  They 
are  said  to  be  larger  in  the  iris,  but  these  have  not  been  examined 
microscopically.  Their  minute  structure  closely  resembles  tubercle, 
but  can  be  distinguished  by  the  presence  of  the  hairs.  The  hairs  act 
as  foreign  bodies,  but  whether  the  irritation  is  purely  mechanical,  due 
to  the  serrated  contour,  or  chemical,  due  to  an  acid  secretion  (formic 
acid  [Goossens])  from  glands  at  the  base,  is  uncertain.  Probably  it  is 
purely  mechanical,  but  the  irritation  seems  to  be  caused  chiefly  by  the 
base,  and  not  the  apex  of  the  hair.  Stargardt  considers  that  the  irri- 
tation is  purely  mechanical  in  the  first  stage,  but  that  later  it  is  due  to 


THE    CONJUNCTIVA  85 

chemical  irritation,  and  it  is  then  that  the  pseudo-tubercles  are  formed. 
The  chief  constituent  of  the  hairs  is  chitin  (glucosamine-acetyl-acetic 
acid,  Schmiedeberg),  and  this  can  split  up  into  glucose  and  aromatic 
products. 

Microscopically  the  hairs  are  found  embedded  in  the  conjunctiva, 
and  surrounded  b)'  an  area  of  dense  round-celled  infiltration.  Peri- 
pherally there  are  usually  numerous  giant-cells  amongst  the  round- 
cells,  and  still  more  peripherally  simple  lymphocytic  infiltration  (Hanke) 
(Fig.  46).  The  giant-cells  may  be  absent  rarely.  With  haematoxylin 
and  eosin  staining,  the  section  of  the  hair  has  a  dark  brown  central 
axis,  surrounded  by  a  strongly  refracting  yellow  zone  (Wagenmann, 
Hanke).  The  round-cells  are  ordinary  lymphocytes  with  deeply 


FIG.  46. — OPHTHALMIA  NODOSA.      x  200. 

The  caterpillar  hair  is  not  seen  in  this  section.     There  is  a  giant-cell  of  the 
Langhans  type,  surrounded  by  epithelioid  cells  and  round-celled  infiltration. 

staining  nuclei  and  scanty  cytoplasm.  The  giant-cells  are  typical 
"  foreign-body  giant-cells,"  with  enormous  cell  bodies  and  very  nume- 
rous nuclei,  which  may  be  arranged  either  centrally  or  peripherally, 
as  in  the  Langhans  giant-cell.  Epithelioid  cells,  with  large,  faintly 
stained  oval  nuclei  and  granular  cytoplasm,  are  numerous  in  the 
vicinity  of  the  giant-cells.  There  are  also  spindle-shaped  cells,  the 
whole  showing  a  tendency  to  concentric  lamination  around  the  hair. 
The  structure  is  well  depicted  in  Kriiger's  plate. 

In  one  of  Kruger's  cases  the  nodules  were  surrounded  by  a  thick 
fibrous-tissue  capsule,  due  probably  to  the  prolonged  irritation,  and  the 
round-cells  were  degenerated,  the  nuclei  staining  badly.  The  nodules 
shrink  and  ultimately  disappear  if  left  alone,  but  scarring  may  lead  to 
permanent  deformity — most  serious  in  the  case  of  the  iris. 


86  THE    PATHOLOGY    OF   THE    EYE 

The  superficial  epithelium  is  normal,  or  somewhat  thickened 
(Wagenmann).  The  conjunctival  stroma  is  oedematous  or  sclerosed, 
the  vessels  being  congested  and  surrounded  by  a  zone  of  lymphocytic 
infiltration,  or  having  sclerosed  walls  (Hanke,  Wagenmann).  These 
differences  are  doubtless  due  to  the  duration  of  the  complaint. 

The  hairs  are  usually  extremely  fine,  covered  with  imbricated  cells. 
These  in  Cnethocampa  processioned  are  arranged  in  the  form  of  a 
screw,  and  have  short  points  (Lord  Walsingham  in  Lawford's  paper). 
The  apex  of  the  hair  is  very  sharp,  and  the  base  tapers,  but  the  hair  is 
often  fractured.  Owing  to  the  imbrication  it  seems  probable  that  the 
hair  travels  base  forward,  its  progress  being  effected  by  the  movements 
of  the  eyes  and  lids,  and  the  rubbing  of  the  eyes  induced  by  the  irrita- 
tion. That  the  hairs  can  travel  far  in  the  course  of  time  is  rendered 
probable  by  the  case  reported  by  Reis,  where  a  hair  was  almost 
certainly  visible  in  the  choroid  ophthalmoscopically.  There  seems  to  be 
no  sufficient  ground  for  Wagenmann's  suggestion  of  definite  chemical 
irritation,  but  the  point  is  not  decided.  The  secretion  of  the  basal 
glands  is  said  to  pass  into  the  empty  hair-shaft  (H.  Karsten,  Leydig, 
Goossens,  C.  Keller).  Hanke  eliminated  the  question  of  subsidiary 
bacterial  infection ;  there  were  no  tubercle  bacilli  by  Ziehl-Neelsen 
stain,  nor,  indeed,  any  micro-organisms  by  Loffler's  method. 

Experiments  on  animals  by  Kriiger  and  Stormann  have  led  to  no 
very  definite  results.  Conjunctivitis  was  set  up,  but  no  nodules  were 
produced,  and  the  hairs  never  reached  the  iris.  It  is  said  that  drying 
the  hairs  renders  them  innocuous,  but  this  requires  confirmation. 
Further  experiments  have  been  made  by  Stargardt. 

Hanke  suggests  that  the  nodules  are  due  to  "  embolism  of  the 
smallest  capillaries  .  .  .  due  to  the  hairs " — not  a  very  probable 
hypothesis. 

PAGENSTECHER.— K.  M.  f.  A.,  xxi,  1883.  BAAS.— K.  M.  f.  A.,  xxvi,  1888.  WEISS.— 
A.  f.  A.,  xx,  1889.  WAGENMANN. — A.  f.  O.,  xxxvi,  i,  1890.  KRUGER. — A.  f.  A.,  xxiv,  xxv, 
1892;  A.  of  O.,  xxii,  1893  (tr.).  BECKER. — Berl.  klin.  Woch.,  1892.  HILLEMANNS. — Deut. 
med.  Woch.,  1894.  STORMANN. — Dissert.,  Berlin,  1894.  LAWFORD. — T.  O.  S.,  xv,  1895. 
ELSCHNIG. — K.  M.  f.  A.,  xxxiii,  1895.  NATHANSON. — K.  M.  f.  A.,  xxxv,  1897.  Vossius. — 
Z.  f.  prak.  Aerzte,  1897.  HANKE. — B.  z.  A.,  xxiii,  1898.  GOOSSENS. — Ann.  de  la  Soc. 
Ent.  fran9.,  1881,  1886.  LEYDIG. — Arch.  f.  Anat.  u.  Phys.,  1856.  C.  KELLER. — Kosmos,  xiii. 
REIS. — A.  f.  A.,  xlvi,  1902.  *  STARGARDT. — A.  f.  O.,  Iv,  3,  1903. 

SPRING   CATARRH. 

Spring  catarrh  was  isolated  as  a  disease  sui  generis  by  Saemisch. 
Cases  had  previously  been  described  as  conjunctivitis  lymphatica  by 
Arlt  (1846),  perikeratic  hypertrophy  by  Desmarres,  gelatinous  thickening  of 
the  limbus  by  v.  Graefe,  phlyct&na  pallida  by  Hirschberg.  It  was  called 
conjunctivitis  verrucosa  by  Goldzieher. 

Spring  catarrh  occurs  in  two  situations — as  flat-topped  papules, 
resembling  cobble-stone  pavement,  on  the  C.  tarsi  of  the  upper  lid, 
and  as  a  gelatinous  or  fleshy  hypertrophy  of  the  C.  bulbi  at  the  limbus. 
The  two  forms  are  found  separately  or  combined,  and  may  be  so  slight 
that  there  is  only  conjunctival  injection  with  minimal  thickening. 
Other  parts  of  the  conjunctiva  are  normal. 


THE    CONJUNCTIVA  87 

The  palpebral  papillae  are  large,  flat-topped,  and  polygonal  by 
mutual  pressure  ;  they  are  often  of  cartilaginous  consistence.  They 
may  be  several  millimetres  in  diameter,  and  are  often  broader  than  they 
are  high.  They  have  a  milky  white  shimmer,  which  is  also  seen  over 


FIG.  47. — SPRING  CATARRH.      x  34. 

From  a  specimen  by  Herbert.  A  palpebral  papilla  cut  vertically.  Note  the 
shape,  and  the  thinning  off  of  the  epithelium  on  the  surface  to  the  left.  The  papilla 
contained  many  eosinophile  corpuscles. 

the  lower  tarsus,  where  there  is  merely  thickening  without  papillary 
formation.  In  vertical  section  the  papillae  have  the  shape  of 
the  circumvallate  papillae  of  the  tongue  (Fig.  47).  In  Spicer's  case 
the  pedicle  was  unusually  slender.  They  consist  of  a  mass  of  dense, 
often  hyaline,  fibrous  tissue,  with  comparatively  few  round  and  spindle- 
shaped  cells,  and  scattered  blood-vessels.  The  epithelium  covering 
them  is  thickened  from  the  normal  double  layer  to  five  or  more  layers, 
and  this  is  the  cause  of  the  milky  appearance.  There  are  often  true 


FIG.  48. — SPRING  CATARRH. 

Herbert,  T.  O.  S.,  xix.  A  palpebral  papilla,  showing  very  extensive 
epithelial  downgrowth,  both  in  long  branching  tubules  and  shorter  irregular 
solid  cords. 

papillae  on  the  surface,  and  epithelial  plugs  may  descend  for  some 
distance  into  the  stroma  (Fig.  48).  The  growths  are  rather  of  the 
nature  of  fibromata  than  papillomata  (Spicer). 

The  hyperplasia  at  the  limbus  was  observed  earlier,  and  has  been 


THE    PATHOLOGY    OF   THE    EYE 

investigated  more  fully  than  the  palpebral  condition.  The  nodular 
growths  are  found  chiefly  at  the  outer  and  inner  sides  of  the  cornea, 
which  they  invade  for  a  short  distance.  They  extend  farther  into  the 


FIG.  49. — SPRING  CATARRH,      x  60. 

From  a  specimen  by  Herbert.     From  the  limbus,  showing    downgrowths    of 
epithelium. 

conjunctiva,  and  may  surround  the  cornea  with  a  wall  of  gelatinous 
tissue.  They  are  sharply  limited  on  the  side  of  the  cornea,  in  which 
there  is  often  a  grey  stria,  separated  by  a  zone  of  clear  cornea,  like  an 
arcus  senilis.  The  nodules  never  ulcerate.  Their  structure  is  essen- 


FIG.  50. — SPRING  CATARRH,      x   120. 

From  a  specimen  by  Herbert.  From  the  limbus,  near  a  spot  which  stained 
with  fluoresce'in,  showing  mode  of  absorption  of  epithelial  downgrowths,  eruption 
of  eosinophiles,  etc. 

tially  the  same  as  that  of  the  papillae,  but  the  epithelial  thickening  has 
been  more  often  remarked  than  the  fibrous  undergrowth,  possibly  owing 
to  incomplete  removal.  The  epithelium  is  usually  three  times  the 
normal  thickness,  having  thirty  to  forty  layers  of  cells.  The  normal 


THE    CONJUNCTIVA  89 

papillae  in  this  situation  are  accentuated  and  multiplied,  and 
epithelial  plugs  often  extend  deeply  into  the  tissues  (Vetsch,  Horner) 
(Fig.  49).  These  often  show  nests  and  resemble  epithelioma,  but  the 
basement  membrane  is  always  intact.  The  superficial  cells  are 
flattened  and  may  have  lost  their  nuclei,  but  actual  cornification  has 
not  been  observed.  Reymond  first  pointed  out  the  fibrous  hyperplasia 
as  the  essential  feature  ;  Knus  found  it  occupy  only  one  third  of  the 
section,  whilst  in  Burckhardt's  case  it  was  much  thicker  than  the 
epithelium.  It  consists  of  looser  fibrous  tissue  with  more  cells.  These 
are  of  three  kinds  :  (i)  small  spindle-cells,  deeply  stained,  which  are 
ordinary  connective-tissue  cells ;  (2)  large  clear  oval  cells,  often  with 
karyomitoses — these  are  probably  embryonic  connective-tissue  cells  ; 
(3)  small  round-cells,  deeply  stained,  which  are  infiltrating  lymphocytes. 
As  the  condition  progresses  the  fibrous  tissue  becomes  less  cellular,  and 
firmer  and  more  compact  (Schlub).  The  cells  and  the  connective 
tissue  often  show  peculiar  hyaline  degeneration  in  the  later  stages. 

Schiele  found  enormous  thickening  of  the  epithelium  with  club- 
shaped  downgrowths  in  a  case  of  bulbar  vernal  catarrh.  With  iodine 
solution  the  superficial  cells  stained  mahogany  red,  the  deeper  ones 
wine  red  ;  infiltrating  cells  and  connective-tissue  cells  stained  diffusely. 
Schiele  deduces  the  presence  of  glycogen  in  these  situations. 

Danvers  found  numerous  mast-cells  and  plasma-cells  in  one  case 
San  Felice's  method  of  staining  blastomycetes  failed  to  reveal  any  ;  no 
bacilli  were  found  by  Gram's  stain. 

Herbert  describes  eosinophile  infiltration  of  the  tissues,  and .  the 
presence  of  minute  vesicles  in  the  epithelial  layers  of  the  pedunculated 
growths,  which  are  also  filled  with  the  eosinophile  cells  (Fig.  50).  He 
further  noted  that  in  the  blood  there  was  an  increase  of  10  to  20  per 
cent,  in  the  eosinophile  count ;  this  may,  however,  have  been  due  to 
other  causes,  though  it  was  not  found  in  other  conjunctival  conditions. 
The  secretion  obtained  by  exposing  the  conjunctiva  for  a  short  time 
also  contains  many  eosinophiles. 

The  nodules  do  not  seem  to  alter  much  during  the  quiescent  winter 
period,  but  they  probably  become  more  infiltrated  and  cellular  in  the 
summer. 

SAEMISCH. — In  G.-S.,  iv,  1876.  REYMOXD. — Ann.  di  Ott.,  iv,  1874.  VETSCH.— Inaug. 
Diss.,  Zurich,  1879.  UHTHOFF. — A.  f.  O.,  xxix,  3,  1883.  EMMERT. — C.  f.  A.,  xii,  1888. 
HORNER. — In  Gerhardt's  Handb.  d.  Kinderkrankheiten,  v.  Tubingen,  1889.  KNUS. — Inaug. 
Diss.,  Zurich,  1889.  SCHOEBL. — C.  f.  A.,  xiv,  1890.  TAILOR. — Ann.  di  Ott.,  xx,  1891. 
BURCKHARDT. — Inaug.  Diss.,  Basel,  1894.  *SCHLUB. — A.  f.  A.,  xxxv,  1897.  NATHAXSON. — 
K.  M.  f.  A.,  xxxviii,  1900.  AHLSTROM. — K.  M.  f.  A.,  xxxviii,  1900.  HOLMES-SPICER. — 
T.  O.  S.,  xx,  1900.  SCHIELE. — A.  f.  A.,  xix,  1889.  DANVERS. — Spring  Catarrh  of  the 
Eyes,  London,  1901.  "HERBERT. — Brit.  Med.  Jl.,  1903. 


PEMPHIGUS. 

One  of  the  earliest  cases  of  pemphigus  of  the  conjunctiva  was 
published  by  White  Cooper  (1858) ;  before  that  date — and  since  also— 
it  has  been  confused  with  xerosis.  It  was  described  as  syndesmitis 
degenerative^  by  Stellwag  (1870),  and  as  essential  shrinking  of  the  con- 


go  THE    PATHOLOGY   OF   THE    EYE 

junctiva  by  Kries  (1878),  of  von  Graefe's  clinic,  von  Graefe  (1879) 
propounded  the  identity  of  pemphigus  and  essential  shrinking,  whilst 
Becker  (1879)  admitted  only  the  identity  of  the  latter  with  syndesmitis. 
v.  Graefe's  view  is  now  generally  admitted  (Fuchs  and  others). 

The  condition  is  rare,  5  in  45,000  (Franke),  2  in  22,000  (Pergens) 
amongst  ophthalmic  cases,  o  in  200  (Hebra)  amongst  cases  of  pemphi- 
gus. Cases  may  be  divided  into  (i)  those  with  blebs  on  the  skin,  (2) 
those  with  blebs  on  the  mucous  membranes  (mouth,  nose,  larynx,  etc.), 
(3)  those  with  blebs  on  the  conjunctiva  only,  (4)  those  with  essential 
shrinking  only  (Pergens).  Of  132  cases  collected  by  Pergens,  9  acute 
and  68  chronic  belong  to  the  first  group,  15  to  the  second,  2  to  the 
third,  and  16  to  the  fourth  ;  in  the  remainder  the  aetiology  is  doubtful. 
The  majority  of  the  patients  were  adults,  but  the  ages  vary  from  i  to  78. 
The  prognosis  is  bad  in  all  cases  watched  for  a  prolonged  period ;  the 
best  result  is  a  case  in  which  the  cornea  was  clear  a  year  after  coming 
under  observation  (Marcus  Gunn). 

In  the  earlier  stage  blebs  occur  upon  the  conjunctiva  and  cornea, 
but  these  are  rarely  seen.  The  epithelium  here  is  much  more  delicate  than 
that  of  the  skin,  and  as  only  the  epithelium,  or  even  the  superficial 
layers  alone,  are  raised,  they  are  quickly  torn  and  disintegrated.  The 
denuded  areas  are  then  seen,  and  these  rapidly  become  covered  by  a 
grey  coating,  which  contrasts  with  the  general  reddening  of  the  con- 
junctiva. As  the  spots  cicatrise,  new  blebs  and  ulcers  appear  in  other 
places.  Cicatrisation  is  accompanied  by  excessive  contraction,  resem- 
bling that  occurring  in  keloid  scars.  Slowly  but  surely  the  whole  con- 
junctiva becomes  opaque,  white,  and  tense ;  the  folds  of  transition 
disappear,  and  bands  stretch  vertically  from  the  lids  to  the  globe,  the 
lids  being  finally  retracted.  The  lacrymal  ducts  become  occluded  and 
the  conjunctiva  becomes  dry.  The  cornea  becomes  ulcerated,  and  at 
last  opaque,  and  eventually  total  symblepharon  results. 

The  bullse  of  pemphigus  in  the  skin  occur  in  various  layers  of  the 
epithelium,  or  the  whole  epithelium  may  be  raised  (Radcliffe-Crocker). 
So  it  is  apparently  in  the  conjunctiva.  Franke  found  that  the  outer 
wall  consisted  of  only  two  or  three  layers  of  cells,  and  did  not  therefore 
involve  the  wrhole  thickness.  The  fluid  contents  are  at  first  clear  serum  ; 
later  they  invariably  become  cloudy,  and  contain  fatty  degenerated 
epithelial  cells,  leucocytes,  a  few  red  corpuscles,  and  granular  debris 
and  coagulum  (Schiess). 

Sattler  found  considerable  swelling  of  the  conjunctiva  due  to 
enormous  oedema,  and  swelling  of  the  fibrous  tissue.  There  was  no 
lymphoid  infiltration,  but  this  is  usually  present.  The  whole  stroma 
was  pervaded  by  granular  material,  which  extended  over  the  cornea. 
The  ulcers  are  rapidly  covered  by  a  fibrinous  coagulum,  so  that  a 
pseudo-diphtheritic  membrane  is  produced. 

A  later  stage  is  described  by  Uhthoff.  The  C.  tarsi  showed  a  saucer- 
shaped  depression,  extending  in  places  deep  into  the  tarsus ;  it  was 
filled  with  granulation  tissue.  The  epithelium  was  absent  for  the  most 
part,  but  the  edges  were  covered  with  a  thin,  new-formed  layer.  There 
was  considerable  inflammatory  infiltration,  especially  in  the  upper 
fornix,  with  strongly  developed  papillae.  The  epithelium  showed 


THE    CONJUNCTIVA  91 

mucous  degeneration,  and  was  raised  in  places,  but  did  not  show  any 
typical  blebs. 

Later  still,  as  in  Sachsalber'scase,  the  epithelium  is  much  thickened, 
and  sends  coarse  plugs  down  into  the  subconjunctival  tissue.  The 
superficial  layers  are  horny.  The  adenoid  layer  is  destroyed,  and  the 
submucosa  is  thickly  infiltrated  with  round  and  spindle-shaped  cells. 
It  is  highly  vascular,  and  the  fibrous  tissue  is  enormously  hyper- 
trophied. 

Similar  changes  occur  in  the  cornea,  which  is  transformed  into 
vascular  scar  tissue,  covered  by  thickened,  papillary,  horny  epithelium 
(Baumler).  Deutschmann  examined  the  pterygium-like  growth  which 
occurs  at  the  edge  of  the  cornea,  and  found  greatly  thickened  horny 
epithelium  lying  on  hypertrophied  fibrous  tissue. 

Bacteriology. — The  bacteriology  of  pemphigus  of  the  skin  has  led  to 
discordant  results,  and  the  condition  is  now  regarded  as  due  to  the 
action  of  toxins  upon  the  nerve  centres  (Radcliffe-Crocker).  This  brings 
the  condition  into  line  with  herpes,  and  the  conjunctival  condition 
shows  many  points  of  similarity  with  neuro-paralytic  keratitis. 

It  is  generally  held  that  the  fresh  blebs,  containing  clear  fluid,  are 
sterile  (Loffler,  Uhthoff).  Later,  when  the  fluid  is  turbid,  staphylococci 
(aurens  and  albus),  streptococci,  etc.,  have  frequently  been  found,  but 
must  be  looked  upon  as  contaminations  which  have  wandered  in  from 
the  surface.  Xerosis  bacilli  are  present  in  large  numbers  upon  the 
surface  and  in  the  epithelium,  especially  in  the  later  stages. 

Specific  organisms  have  been  described.  Plimmer  obtained  from 
a  case  of  Silcock's  a  micrococcus  which  was  apparently  identical 
with  that  obtained  by  Demme  and  Bullock  and  Wells,  from  acute 
pemphigus.  It  was  obtained  in  pure  culture  from  a  bleb  on  the 
hand.  It  usually  occurs  as  a  diplococcus,  rather  larger  than  the  gono- 
coccus  ;  forms  round  white  colonies  on  agar  ;  grows  rapidly  in  bouillon 
at  37°  C. ;  well  on  agar  and  serum  ;  badly,  with  slight  liquefaction  in  two 
or  three  weeks,  on  gelatine  at  22°  C.  The  cocci  stain  with  all  aniline 
dyes,  and  by  Gram.  Injected  into  the  peritoneum  of  a  mouse,  they 
caused  death  in  fourteen  hours ;  into  the  pleural  cavity  in  forty-eight 
hours.  Inserted  into  the  scarified  conjunctival  sac  of  a  rabbit,  they 
caused  much  more  rapid  suppuration  than  is  produced  by  other  septic 
organisms. 

Deutschmann  found  a  streptococcus  which  he  considered  "  with 
some  probability"  to  be  specific.  Inoculation  of  a  rabbit's  ear  caused 
blebs  which  contained  the  organism. 

WHITE  COOPER. — R.  L.  O.  H.  Rep.,  i,  1858.  STELLWAG. — Lehrbuch  d.  Augenheilkunde, 
6th  ed.,  1870.  KRIES. — A.  f.  O.,  xxiv,  i,  1878.  RADCLIFFE-CROCKER. — Diseases  of  the 
Skin,  London,  1903.  SCHIESS  (-GEMUSEUS). — Jahresb.  d.  Augenheilanstalt  zu  Basel,  1889. 
SATTLER. — B.  d.  o.  G.,  1879.  UHTHOFF. — Berliner  klin.  Woch.,  1893.  SACHSALBER. — 
K.  M.  f.  A.,  xxxii,  1894.  BAUMLER. — K.  M.  f.  A.,  xxiii,  1885.  LANG,  CRITCHETT  AND 
JULER.— T.  O.  S.,  vi,  1886.  MARCUS  GUNN.— T.  O.  S.,  xiii,  1893;  xv,  1895.  FERNET.— 
Brit.  Med.  Jl.,  1895;  Tr.  Derm.  Soc.,  iii,  1897.  FERNET  AND  BULLOCK. — Brit.  Jl.  of 
Derm.,  viii,  1896.  SILCOCK. — T.  O.  S.,  xvii,  1897.  DEUTSCHMANN. — B.  z.  A.,  ii,  1891  ; 
Munch,  med.  Woch.,  1898.  v.  MICHEL. — Z.  f.  A.,  iii,  1900.  *FRANKE. — Der  Pemphigus 
u.  d.  essent.  Schrumpfung  d.  Bindehaut  d.  Auges,  Wiesbaden,  1900.  *PERGENS. — Pemphi- 
gus des  Auges,  Berlin,  1901. 


92  THE    PATHOLOGY    OF   THE    EYE 


CONJUNCTIVITIS  PETRIFICANS. 

Conjunctivitis  petrificans  is  a  rare  disease,  first  described  by  Leber 
in  1895.  The  full  report  of  his  cases  is  a  model  of  exhaustive  investiga- 
tion. Another  case  has  been  reported  by  Reif. 

The  conjunctiva  is  inflamed  and  covered  with  opaque  white  spots  or 
plaques,  which  project  little  above  the  surface,  and  are  not  due  to 
exudate,  but  to  an  altered  condition  of  the  tissue  itself.  They 
commence  as  small  round  or  irregular  spots,  of  chalky  whiteness, 
which  gradually  extend  superficially  and  in  depth,  involving  more  and 
more  of  the  bulbar  and  palpebral  conjunctiva.  The  lower  part  of  the 
scleral  conjunctiva  and  neighbouring  part  of  the  fornix  seem  to  be  first 
attacked,  but  it  also  commences  simultaneously  in  different  parts. 
New  spots  apparently  arise  also  by  contact  infection,  and  both  eyes 
may  be  involved.  The  conjunctivitis  is  relatively  slight.  The  surface 
of  the  larger  plaques  is  uneven  and  stony  hard.  The  cornea  does  not 
usually  suffer  severely.  The  affection  is  chronic,  marked  by  severe 
exacerbations,  but  ultimate  recovery  may  ensue. 

Microscopically  the  epithelium  is  absent  in  parts,  in  others  irregu- 
larly thickened.  It  may  contain  calcareous  crystals.  The  stroma 
shows  proliferation  of  connective  tissue,  with  deposits  of  calcareous 
salts.  These  are  partly  inorganic  salts — carbonates  and  phosphates, — 
partly  organic,  as  shown  by  their  solubility  in  alkalies.  The  calcified 
part  forms  a  superficial  zone  permeated  by  crystals  and  fine  amorphous 
particles,  which  are  partly  diffuse  and  partly  clumped.  On  decalcifica- 
tion  the  substratum  is  partly  homogeneous,  partly  composed  of  coarse 
masses,  especially  in  the  deeper  areas.  The  deep  zone,  below  the 
calcareous  zone,  consists  of  fibrous  tissue  in  active  proliferation.  The 
fibroblasts  are  increased  in  size  and  number,  and  the  tissue  is  infiltrated 
with  round-cells.  The  fibrous  bundles  are  irregularly  thickened,  and 
show  hyaline  degeneration ;  in  places  they  are  infiltrated  with  fibrinous 
coagula,  and  elsewhere  are  wholly  necrotic.  The  deep  vessels  show 
endothelial  proliferation ;  in  one  case  they  were  blocked  by  hyaline 
thrombi,  and  the  walls  showed  hyaline  degeneration.  The  hyaline 
material  showed  every  gradation  of  stain  to  the  fully  developed  amyloid 
condition,  but  the  latter  was  small  in  amount.  The  layer  between  the 
superficial  and  deep  zones,  the  "  petrification  zone,"  contained  sheaves 
and  rosettes  of  calcareous  crystals.  Even  in  parts  where  no  deposits 
could  be  seen  the  tissue  contained  an  excess  of  lime  salts,  octahedra 
of  calcium  oxalate  being  deposited  on  the  addition  of  oxalic  acid. 

Giant-cells  were  found  in  one  case  in  contact  with  the  calcified 
material ;  they  were  the  ordinary  irritation  giant-cells  (so-called 
foreign-body  giant-cells).  A  noteworthy  feature  was  the  enormous 
aggregation  of  eosinophile  leucocytes  beneath  and  within  the  necrotic 
part. 

In  one  case  all  the  other  features  were  present  without  any  necrosis. 

Leber  regards  the  condition  as  a  parasitic  one,  though  he  failed  to 
obtain  positive  results  by  staining,  culture,  or  inoculation.  The  massing 
of  eosinophile  cells  in  the  zone  of  infiltration  proves  a  strong  chemo- 


THE    CONJUNCTIVA  93 

tactic  action  of  the  necrotic  tissue  upon  the  leucocytes  in  the  blood. 
They  appear  to  break  up  and  set  free  their  granules,  dissolving  the 
tissues  by  their  histolytic  ferment,  so  far  as  the  calcification  permits. 
The  giant-cells  probably  have  the  same  function. 

The  inflammatory  proliferation  of  connective  tissue  and  endo- 
thelium  is  probably  the  primary  event ;  the  vessel  walls  are  injured, 
and  the  tissues  are  flooded  with  plasma,  which  forms  fibrinous  coagula ; 
these  degenerate  into  hyaline  and  amyloid  material,  becoming  calcified 
by  the  copious  deposition  of  lime  salts.  The  necrosis  is  secondary, 
caused  partly  by  the  blocking  of  the  vessels  by  degeneration  and 
thrombosis,  and  partly  by  the  virulence  of  toxins. 

LEBER. — B.  d.  o.  G.,  1895.     REIF. — A.  f.  O.,  1,  i,  1900.     *LEBER. — A.  f.  O.,  li,  i,  1900. 


DEGENERATIONS. 

CONCRETIONS. 

Concretions  are  of  frequent  occurrence  in  elderly  people  in  the 
lower  fornix,  and  less  frequently  in  the  C.  tarsi.  They  appear,  either 
by  the  naked  eye  or  with  a  loupe,  as  white  or  yellow  specks  arranged  in 
horizontal  rows  or  in  groups.  They  are  often  expressed  by  slight 
manipulation  ;  in  other  cases  they  are  more  deeply  set.  They  are  the 
products  of  degeneration  of  cells  and  mucoid  exudate  in  the  lumen  of 
minute  cysts  (v.  infra}. 

The  cysts  are  retention  cysts  of  glands  of  new  formation,  due  to 
irritation,  and  also  of  the  so-called  Henle's  glands.  They  are  surrounded 
by  an  area  of  lymphocytic  infiltration.  Their  walls  consist  usually  of 
a  double  layer  of  epithelium,  the  inner  layer  being  cubical  or  cylin- 
drical, with  numerous  goblet-cells  (Fig.  51).  The  epithelium  is  usually 
intact,  but  may  be  flattened  by  the  pressure  of  the  concretions,  or 
absent  in  places  from  atrophy,  or  thickened  by  proliferation.  Some  of 
the  cells  are  swollen  and  degenerated,  others  are  cast  off  into  the 
lumen  and  help  to  form  the  basis  of  the  concretions  (Wintersteiner). 
They,  however,  play  a  relatively  small  part,  and  their  co-operation  could 
not  be  proved  by  Fuchs.  Both  authors  agree  in  their  descriptions  of 
the  concretions,  and  their  conclusions  can  easily  be  confirmed  by 
anyone. 

Each  space  contains  one  to  five  concretions — usually  one  only, — but 
all  are  built  up  by  aggregation.  They  are  usually  hyaline,  with  faint 
or  well-marked  lamination  (Fig.  52),  best  seen  at  the  periphery,  though 
many  have  radial  striations  here.  Like  all  these  degeneration  products, 
they  stain  variously  according  to  their  chemical  constitution.  They 
stain  very  well  with  safranin  (Wintersteiner),  red  with  eosin,  peri- 
pherally or  in  zones  with  haematoxylin,  variably  with  fuchsin,  not  at 
all  with  carmin,  yellow  with  van  Gieson,  violet  in  parts  with  Gram, 
not  at  all  by  Loffler's  methylene  blue,  red  with  orseille.  They  do  not  con- 
tain calcium  carbonate  or  phosphate,  give  no  xanthoproteic,  murexide,- 
or  amyloid  reactions  (Fuchs).  They  are  stained  blue  by  thionin,  faint 


94 


THE    PATHOLOGY   OF   THE    EYE 


brown  or  violet  with  vesuvin,  faint  violet  with  mucicarmin.  They 
do  not,  therefore,  give  mucin  reactions.  They  belong  to  that  indeter- 
minate quantity — v.  Recklinghausen's  hyalin  (v.  infra).  Both  dyes  and 
culture  experiments  fail  to  show  the  presence  of  bacteria,  actinomyces 
(cf.  orseille),  or  botryomyces  (Fuchs). 

Besides  a  variable  amount  of  inflammatory  infiltration  in  the  con- 
nective tissue,  with  occasional  mast-cells  and  nodules  of  brown  pig- 
ment, small  hyaline  globules  are  often  present,  as  in  other  conditions, 
e.  g.  trachoma.  They  are  not  of  any  pathogenic  importance. 

The  stages  in  the  formation  of  these  hyaline  bodies  have  been 
exhaustively  worked  out  by  Fuchs.  Numerous  polymorphonuclear 
leucocytes  infiltrate  the  epithelium,  and  are  present,  usually  much 


FIG.  51. — CONCRETIONS  IN  THE  CONJUNCTIVA,     x  55. 

The  concretions  are  contained  in  new-formed  glandular  depressions,  which  are 
cut  across.  The  walls  of  the  cystic  spaces  are  lined  with  goblet-cells,  many  of 
which  have  discharged  their  contents.  Some  glands  are  seen  which  do  not  contain 
concretions. 

degenerated,  in  the  lumen.  Their  nuclei  often  form  branching  fila- 
ments with  nodular  enlargements  amongst  the  cells,  similar  to  those 
described  by  Peters  in  conjunctivitis  (v.  p.  56).  Many  lumina  are 
empty  ;  others  contain  homogeneous  or  finely  granular  lumps  or  net- 
works. Mono-  or  polymorpho-nuclear  cells,  or  both,  are  often  present, 
usually  bereft  of  a  definite  cell  body.  They  are  also  found  in  cystic 
spaces  in  the  epithelium,  frequently  sickle-shaped  with  a  cell  body. 
Nuclear  fragments  and  clumps  occur.  Swollen  epithelial  cells  are 
found  in  the  walls  and  free  in  the  lumen  ;  the  latter  swell  into  granular 
masses  and  their  nuclei  degenerate,  or  they  stain  deeply  with  eosin 
and  retain  their  nuclei  (Wintersteiner). 


THE    CONJUNCTIVA 


95 


The  smallest  concretions  seem  to  be  swollen  nuclei  (Fuchs)  ;  these 
fuse,  showing  larger  bodies  with  crenate  edges.  Laminated  con- 
cretions are  found  embedded  in  deeply  staining  nuclei.  Larger,  more 
faintly  staining  ones  with  indications  of  a  nucleus  are  seen.  These  are 
probably  of  epithelial  origin.  Others  fuse  into  complex,  tubularly 
arranged  masses,  each  tubule  having  a  darker,  radially  striated  cortex. 
Increase  in  density  occurs  both  at  the  periphery  and  in  the  nucleus  in 
different  cases,  and  in  this  manner  laminae  may  be  laid  down  re- 
sembling a  renal  calculus.  The  concretions  may  grow  out  of  the 
mouth  of  the  gland  and  project  from  the  surface,  or  the  mouth  may  be 
closed  by  a  mass  of  cells.  The  smaller  bodies  are  often  surrounded  by 


FIG.  52. — CONCRETIONS  IN  THE  CONJUNCTIVA,    x  55. 

The  concretions  are  distinctly  laminated,  and  stain  variably  with  haematoxylin 
and  eosin.  They  are  contained  in  glandular  cystic  spaces  in  a  pigmented  naevus 
of  the  plica  semilunaris  removed  from  an  elderly  man. 

a  homogeneous  layer  of  mucoid  substance,  but  in  no  case  do  these 
mucoid  deposits  give  true  mucin  reactions.  In  some  cases  there  is  a 
membranous  covering,  which  spans  the  crenations,  and  is  best  seen 
when  raised  from  the  concretion  near  the  mouth  of  the  gland.  It 
resembles  an  endothelial  membrane,  and  is  in  places  definitely 
cellular. 

Concretions  with  radial  striations  of  the  periphery  much  resemble 
actinomycetes,  and  were  erroneously  described  as  such  by  de  Vincentiis 
in  one  case,  and  by  Fuchs  in  his  earlier  communication  to  the  Ophthal- 
mological  Society  at  Heidelberg.  This  has  been  disproved  by  Fuchs' 
later  researches  and  by  Wintersteiner.  Faber  published  a  case  as 


96  THE    PATHOLOGY    OF   THE    EYE 

botryomycosis,  similar  to  the  condition  found  in  horses,  but  this  is  also 
probably  a  mistake. 

Antonelli  found  hyaline  concretions  in  cysts  of  Krause's  glands ;  in 
this  case  he  was  able  to  trace  the  development  from  blood-clot. 
Wintersteiner  described  laminated  concretions,  exactly  similar  to  the 
ordinary  conjunctival  ones,  in  cysts  of  Krause's  gland  ;  the  presence  of 
typical  foreign-body  giant-cells  was  peculiar  to  this  case,  but  might 
well  occur  in  all  cases,  and,  indeed,  indications  of  their  formation  are 
not  wanting. 

Mitvalski  reported  similar  "colloid  pearls  "  of  the  Meibomian  glands. 

ANTONKLLI. — Ann.  di  Ott.,  xix,  1890.  DE  VINCENTIIS. — Lav.  d.  Clin.  oc.  di  Napoli, 
iii,  1891-3.  MITVALSKI. — C.  f.  A.,  xxi,  1897.  FABER. — 38  Jahresb.  der  Augenheilanstalt  in 
Utrecht,  1897.  *FUCHS. — B.  d.  o.  G.,  1896;  A.  f.  O.,  xlvi,  i,  1898.  WIXTERSTEINER. — 
A.  f.  O.,  xlvi,  2,  1898. 


HYALINE,  COLLOID,  AND  AMYLOID  DEGENERATION. 

Degenerative  changes,  leading  to  the  formation  of  homogeneous 
material,  are  of  frequent  occurrence  in  all  parts  of  the  eye,  as  also  else- 
where in  the  body.  The  material  varies  very  much  in  its  staining 
reactions,  undoubtedly  owing  to  its  variable  chemical  constitution.  It 
has  therefore  received  various  names,  such  as  hyaline,  colloid,  amyloid, 
etc.,  and  this  has  led  to  great  confusion.  In  all  probability  these  sub- 
stances are  entirely  formed  from  exudates  or  secretions,  i.  e.  from  the 
non-living  products  of  living  cells.  In  some  cases  this  must  be  con- 
sidered a  physiological  process,  as,  e.g.,  when  Descemet's  membrane 
is  laid  down  by  the  agency  of  the  endothelial  cells,  the  lens  capsule  by 
the  epithelial  cells,  Bruch's  membrane  by  the  pigment  epithelium  of 
the  retina,  etc.  In  others  it  is  a  pathological  process,  which  may  be 
allied  to  the  physiological,  as  in  the  formation  of  the  so-called  "colloid" 
bodies  of  the  choroid,  etc.,  but  is  more  commonly  due  to  chemical 
changes  in  exudates  derived  from  the  lymph  or  blood-plasma.  Most 
of  these  exudates  are  proteids,  or  consist  chiefly  of  proteids.  They  are 
inert,  dead  material,  lying  amongst  living  cells,  and  their  subsequent 
fate  depends  upon  their  environment.  This,  in  turn,  varies  with  the 
general  conditions  of  the  organism,  as  well  as  with  the  exact  local 
disposition,  such  as  relationship  to  vessels,  cells,  etc.  Hence  it  is  not 
surprising  that  the  changes  these  exudates  undergo  differ  in  widely 
divergent  ways.  Some  are  mere  plasmatic  coagula,  others  contain 
living  or  dead  leucocytes.  The  first  stage  is  often  the  formation  of  a 
network  of  fibrin,  and  this  may  simply  disappear,  forming  the  pabulum 
of  rapidly  growing  fibroblasts,  or  melting  by  ferment  action  into  soluble 
proteids,  which  are  carried  off  in  the  lymph-stream.  In  less  active 
conditions — marasmic,  senile,  and  so  on — the  exudates  stagnate. 
They  then  undergo  chemical  changes,  whereby  they  slowly  alter  from 
substances  giving  all  the  proteid  reactions  to  substances  which  give 
only  "albuminoid"  reactions,  and  these  vary  much  amongst  themselves. 
Some  have  fairly  definite  colour  reactions  ;  if  they  stain  mahogany- 
brown  with  iodine  and  pink  with  methyl  violet,  they  are  called 


THE    CONJUNCTIVA  97 

amyloid,  and  this  seems  to  be  a  fairly  stable  entity.  Often,  however, 
the  reaction  is  indeterminate ;  parts  fail  to  show  the  reaction,  others 
show  it  well,  whilst  yet  others  give  intermediate  tints.  We  are  dealing 
with  mixtures,  or  with  bodies  in  a  state  of  chemical  change.  These 
facts  must  be  carefully  borne  in  mind  whenever  we  speak  of  hyaline 
bodies  or  degeneration,  etc.  The  earlier  observers  did  not  always 
realise  them,  and  it  will  be  necessary  to  refer  to  their  views  ;  but  many 
of  the  apparent  contradictions  are  due  to  these  facts,  and  many  of  the 
divergent  views  are  but  the  expression  of  divergent  processes.1 

Since  the  word  "  hyaline "  has  not  obtained  so  determinate  a 
significance  as  "  colloid,"  etc.,  and  is  less  liable  to  lead  to  confusion,  it 
will  generally  be  used  throughout  the  following  pages.  It  must,  there- 
fore, be  considered  to  have  a  very  wide  significance,  and  not  even  so 
restricted  a  one  as  v.  Recklinghausen's,  which  may  be  termed  "hyalin" 
for  distinction. 

v.  Recklinghausen  described  a  substance  which  he  called  "hyalin," 
and  which  had  the  following  peculiarities : 

1.  It  was  homogeneous  and  highly  refractile. 

2.  It  was  extremely  resistent  to  reagents,  being  insoluble  in  strong 
acids  and  alkalies. 

3.  It  stained  deeply  with  dyes,  especially  eosin  and  acid  fuchsin, 
also    carmin,    picrocarmin,    safranin,    etc.,    less    and    more    variably 
with  haematoxylin  ;  but  it  did  not  give  the  characteristic  amyloid  re- 
actions. 

Raehlmann  first  described  this  substance  in  the  conjunctiva;  he 
found  it  in  adenoid  tumours  growing  from  the  caruncle  and  lower 
fornix.  He  found  it  both  alone  and  in  conjunction  with  amyloid 
tumours,  and  he  regards  hyalin  as  a  precursor  of  amyloid,  in  which 
view  he  is  supported  by  his  pupil  Kubli.  Vossius,  on  the  other  hand, 
in  describing  two  cases  of  hyaline  degeneration  of  the  conjunctiva, 
distinguishes  strongly  between  hyalin  and  amyloid.  They  occurred  in 
young  people,  free  from  any  constitutional  defect,  though  they  had  had 
trachoma.  In  one  case  both  eyes  were  affected,  in  the  other  only  one 
upper  lid.  Firm,  smooth,  pale  reddish-yellow  tumours  grew  from  the 
neighbourhood  of  the  fornix ;  some  were  furrowed,  resembling  the 
cerebral  convolutions.  They  consisted  of  masses  of  adenoid  tissue 
with  hyaline  degeneration,  which  gave  reactions  corresponding  with 
v.  Recklinghausen's  hyalin.  The  fibrous  tissue  of  the  reticulum  was 
irregularly  swollen  and  homogeneous,  and  in  places  massed  into  large 
irregular  nodules ;  the  cells  were  atrophied  by  pressure.  The  larger 
blood-vessels  showed  endo-  and  peri-vasculitis,  amounting  in  many 
cases  to  endarteritis  obliterans.  The  thickened  walls  were  hyaline, 
with  a  fine  concentric  lamination,  possessing  few  or  no  nuclei.  The 
walls  of  the  capillaries  were  transformed  into  thick  hyaline  tubes,  with 
much  constricted  lumen. 

Kamocki  has  also  reported  a  case. 

Both  the  hyaline  and  the  true  amyloid  degeneration  of  the  con- 
junctiva seem  to  be  extremely  rare  everywhere  except  in  Russia. 

1  See  PARSONS,  Drusen,  T.  O.  S.,  xxiii,  1903. 


98  THE    PATHOLOGY   OF   THE    EYE 

v.  Oettingen  described  the  first  case  of  amyloid  degeneration  of  the 
conjunctiva  in  1871,  and  the  subject  has  been  well  investigated  by 
Raehlmann  and  Kubli,  of  the  Dorpat  Clinic,  and  by  Vossius.  The 
disease  usually  occurs  in  people  from  twenty  to  thirty-five  years  old,  and 
is  extremely  chronic,  and  incurable.  Many  cases  are  associated  with 
trachoma,  but  this  is  purely  incidental,  since  it  may  be  circumscribed  in 
an  otherwise  healthy  conjunctiva  (Reymond).  The  patients  may  also 
be  quite  healthy,  thus  differing  from  cases  of  amyloid  disease  of  the 
intestines,  spleen,  kidneys,  etc.  The  onset  is  insidious  and  the  pro- 
gress slow,  but  is  occasionally  rapid.  Only  one  eye  is  usually  affected. 
It  involves  particularly  the  upper  fornix  and  the  plica  semilunaris, 
avoiding  the  more  firmly  attached  parts.  Kubli  distinguishes  four 
phases  :  (i)  simple  adenoid  proliferation  ;  (2)  hyaline  degeneration  ; 
(3)  amyloid  degeneration ;  (4)  calcification  and  ossification. 

The  earliest  stages  are  described  by  Raehlmann.  The  epithelium 
is  intact ;  the  subepithelial  tissue  is  packed  with  lymphocytes,  the 
adenoid  layer  being  enormously  increased.  The  structure  is  that  of 
ordinary  lymphoid  tissue — a  fine  reticulum,  with  nuclei  at  the  nodes 
and  round-cells  in  the  meshes.  The  latter  are  degenerated  in  patches, 
forming  hyaline  masses  from  which  the  nuclei  have  disappeared. 
They  are  stained  by  tannate  of  iron  (Raehlmann).  The  vessels  show 
hyaline  degeneration,  the  walls  being  transformed  into  broad  homo- 
geneous rings.  There  is  no  amyloid  reaction  in  the  early  stages,  but 
later  both  hyalin  and  amyloid  and  intermediate  forms  occur  simul- 
taneously. 

Herbert  has  described  a  case  of  hyaline  degeneration  of  the  con- 
junctiva ;  he  prefers  the  term  "  colloid  "  degeneration,  by  analogy  to 
similar  processes  occurring  in  the  skin  (Unna).  With  iodine  the  sub- 
stance stained  pale  brown  ;  with  iodine  and  sulphuric  acid,  faint  indigo 
blue,  "possibly  due  to  cholesterine;"  with  methyl  violet  and  gentian 
violet  there  was  no  trace  of  pink  coloration. 

On  account  of  the  application  of  Unna's  methods  to  the  investi- 
gation of  this  case,  it  merits  more  than  passing  notice.  Herbert 
describes  his  results  as  follows  : 

"  In  most  sections  the  epithelium  is  found  thickened,  and  this  is 
more  by  swelling  of  the  cells,  which  are  rounded,  than  by  increase  in 
their  number.  There  are  mucus-cells  among  them,  but  they  are  ab- 
normal in  retaining  the  blue  colour  of  polychromic  methylene  blue  on 
decolourising  with  glycerine-ether  mixture  (Fig.  53). 

"  Below  the  epithelium  is  a  layer  of  lymphoid  tissue  of  varying 
thickness;  its  occurrence  is,  of  course,  quite  abnormal  in  the  ocular  con- 
junctiva. The  cells  are  more  widely  separated  than  in  ordinary 
adenoid  tissue,  especially  close  beneath  the  epithelium.  Lying  between 
them  is  a  quantity  of  swollen  material  disposed  in  ill-defined  and 
irregular  lumps,  and  small  fragments  and  bands,  whose  origin  from 
normal  connective-tissue  fibres  (collagen)  can  be  traced  only  with  some 
difficulty,  owing  to  the  advanced  stage  of  the  process.  It  requires  care 
to  make  certain  that  the  swollen,  broken-up,  and  rearranged  tissue  is 
not  a  deposit  or  infiltration  replacing  normal  collagenous  fibres 
absorbed.  This  is  the  very  rare  change  which  has  been  described  in 


THE    CONJUNCTIVA 


99 


the  skin  as  colloid  degeneration.1  The  colloid  material  has  no  very 
striking  staining  peculiarities ;  it  takes  up  orcem  well,  as  does  normal 
collagen.  Here  and  there  in  the  deeper  part  of  this  layer  is  seen 
enclosure  (partial  or  complete)  of  the  cells  in  rings  of  colloid.  A  few 
lymphocytes  are  so  closely  invested  that  the  appearance  is  given  of 
colloid  transformation  of  the  protoplasm  of  a  cell.  The  larger  cells, 
plasma-cells,  lie  loosely  within  the  rings,  not  in  close  contact  with 
them.  There  are  a  few  scattered  hyaline  balls  to  be  found.  This  is 
the  true  hyaline  degeneration  which  has  been  exhaustively  described  2 
in  other  parts  of  the  body,  and  is  found  sparingly  in  trachoma  follicles, 
in  enormous  quantity  in  transverse  corneal  films,  etc.  Here  and  there 
an  unusual  yellowish  tint  is  noticeable  in  some  of  the  spheres  stained 
with  acid  fuchsin ;  possibly  this  colour  is  derived  from  the  blood  which 


u?^v 


Fir..  53. — "COLLOID"  DEGENERATION  OF  THE  CONJUNCTIVA,      x   144. 

After  Herbert,  T.  O.  S.,  xxii,  pi.  xix.  Stained  by  acid  orce'in,  haematoxylin, 
acid  fuchsin,  and  picric  acid  -.  showing  epithelium  above  with  swollen  cells,  the 
deeper  tissues  infiltrated  with  leucocytes  and  containing  hyaline  masses.  Note  the 
deeply  stained  elastic  fibres  near  dilated  blood-vessels. 

recently  infiltrated  the  tissue.  To  the  same  source  is  to  be  attributed 
the  numerous  particles  of  golden-yellow  pigment  lying  among  the  cells. 
"  The  colloid  change  is  still  more  developed  throughout  the  deeper 
tissues,  which  consist  mainly  of  large,  sharply  defined,  rounded,  and 
elliptical  free  blocks  of  colloid.  The  coalescence  and  moulding  of  the 
material  into  these  masses  is  probably  largely  due  to  constant  stretching 
and  movement  of  the  loose  conjunctival  fold  under  the  working  of  the 
upper  lid.  The  centres  of  many  of  the  blocks  stain  very  feebly,  and  in 
many  there  are  definite  central  cavities.  Some  of  these  masses 
certainly  represent  sections  of  the  fragmentary  remains  of  blood- 
vessels, for  occasionally  more  or  less  definite  relics  of  endothelium  and 

1  See  UNNA,  Histopathology  of  the  Diseases  of  the  Skin,  London,  1896. 

2  See  UNNA,  loc.  cit. 


TOO  THE    PATHOLOGY   OF   THE    EYE 

concentric  elastic  fibres  can  be  made  out  in  them.  Others,  with  large 
cavities,  enclose  various  contents — in  most  cases  a  single  plasma-cell, 
rarely  a  smaller  piece  of  colloid  or  a  small  collection  of  golden  blood- 
pigment.  Here  and  there  the  enclosure  is  incomplete,  the  two  ends  of 
the  encircling  band  of  colloid  not  having  yet  joined  together.  These 
and  rarer  appearances  explain  how  the  cells,  etc.,  become  completely 
surrounded.  Embedded  in  the  substance  of  a  few  of  the  blocks — not 
lying  free  in  spaces — are  small  spheres,  the  larger  of  them  having  con- 
centric markings,  which  are  usually  seen  stained  exactly  like  the  mass 
in  which  they  lie,  and  are  recognisable  only  by  a  different  refractive 
index.  Other  blocks  without  hollow  centres  are  seen,  after  staining 
with  acid  fuchsin,  to  contain  degenerating  collagenous  fibres,  disposed 
either  in  a  central  coil  or  network,  or  ramifying  throughout  the  mass. 
Prolonged  staining  with  acid  orcei'n  shows  in  a  smaller  number  de- 
generating elastic  fibres  similarly  embedded  ;  they  are  of  very  uneven 
thickness,  some  of  them  separating  into  fragments.  Complete  fusion 
of  elastic  fibres  into  a  block  is  occasionally  seen  by  its  staining  darkly 
with  acid  orcei'n  ;  the  result  has  been  named  by  Unna  '  collastin.' 
Many  of  the  blocks  have  connective-tissue  cells  closely  applied  to  them, 
following  their  curves  ;  this  corresponds  with  the  former  close  contact 
between  such  cells  and  the  connective-tissue  bundles. 

"  There  are  still  a  few  bands  of  white  connective  tissue  (collagen) 
remaining,  which  have  resisted  the  early  colloid  change,  and  which 
appear  to  be  degenerating  in  a  direction  somewhat  apart.  They  colour 
abnormally,  deeply  both  with  acid  fuchsin  and  acid  orcein  ;  in  parts 
the  separate  fibrils  may  be  seen  swollen  and  breaking  down  into  drop- 
lets and  small  fragments.  Such  bands  pass  obliquely  through  the 
tissues,  and  in  parts  of  most  of  the  sections  there  is  one  lying  imme- 
diately beneath  the  superficial  adenoid  layer  of  conjunctiva.  There  is 
very  little  free  elastic  tissue  remaining  ;  what  there  is  is  mostly  clumped 
and  coiled  in  the  neighbourhood  of  blood-vessels.  Some  of  the  fibres 
are  swollen,  and  apparently  melting  down.  Appropriate  staining  may 
show  basophile  degeneration — elacin.  The  blood-vessels  are  mostly 
profoundly  altered.  On  the  one  hand  there  is  colloid  thickening  of  the 
walls  (of  arterioles  ?),  resulting  in  occlusion  and  breaking  up  into 
blocks.  On  the  other  hand  may  be  seen  rarefaction  ot  walls  (of 
venules  ?)  with  dilatation.  Outside  the  endothelial  lining  a  scanty 
collagenous  network  encloses  a  chain  of  spaces  enclosing  lymphocytes. 
In  the  neighbourhood  there  are  a  few  lymphocytes  collected,  and  some 
strips  and  fragments  of  forming  colloid.  The  weakness  of  the  walls  of 
the  blood-vessels  explains  the  tendency  to  haemorrhage  on  bruising ; 
the  lack  of  supporting  tissue  is  also  a  factor,  while  on  the  other  hand 
it  permits  of  immediate  closure  of  vessels  completely  torn  across. 

"  A  still  further  change  is  seen  here  and  there  in  the  deeper  tissues — 
coalescence  of  colloid  into  larger  masses.  This  in  excess  leads  to  the 
rather  firm,  waxy  nodules  seen 'clinically.  Such  a  nodule  consists  of 
two  portions — (i)  a  more  compact  centre,  and  (2)  a  looser  periphery. 
In  the  former  there  is  no  trace  of  blood-vessels,  and  only  the  remains 
of  cells.  These  consist  of  groups  of  small  granules  and  of  larger 
spheres.  They  can  be  shown  fairly  well  by  hsematoxylin,  which  they 


THE    CONJUNCTIVA  101 

retain  better  than  the  surrounding  colloid.  In  the  peripheral  parts  the 
colloid  is  laid  down  in  long  strips  or  layers,  perhaps  corresponding 
with  the  original  connective-tissue  bundles.  The  easily  moulded  new 
material  has  been  protected  from  the  influence  of  movement  in  the 
conjunctival  fold  by  proximity  to  the  firm  central  mass;  hence  the 
absence  of  rounded  blocks.  Between  the  strips  are  numerous  cells, 
mostly  plasma-cells,  but  also  eosinophile,  and  a  few  polynuclear 
leucocytes,  large  '  mast-cells,'  and  some  large  branched  cells  con- 
taining much  pigment.  There  are  also  blood-vessels." 
Amyloid  substance  gives  the  following  reactions  : 

1.  Iodine  Reaction  (Virchow). — Mahogany  brown  with  iodine. 

2.  Iodine    and    Sulphuric    Acid   Reaction    (Langhans). — The    brown 
produced  by  iodine  is  turned  darker  or  passes  into  violet,  blue,  or  green 
on  further  addition  of  dilute  sulphuric  acid. 

3.  Methyl-violet    or    Gentian-violet   Reaction. — Purple    or   pink,    the 
other  tissues  being  blue. 

4.  Methyl-green  Reaction. — Violet,  the  other  tissues  being  green. 

5.  Iodine-green  Reaction. — Violet,  after  prolonged  staining  (twenty- 
four  hours),  the  other  tissues  being  green. 

6.  Thionin  Reaction  (Kantorowicz) . — Lilac-blue,  the  other  parts  being 
violet. 

7.  Polychrome-methylene-blue  Reaction. — Pink,  the  other  parts  being 
blue. 

8.  Bismarck-brown  and  Gentian-violet  Reaction  (Birch-Hirschfeld). — 
Bright  red,  the  other  tissues  being  brown. 

9.  Picro-borax-carmin   Reaction    (Neumann]    (see    Vossius). — Yellow 
against  the  red  or  orange  of  other  parts. 

In  the  fully  developed  condition  large  sago-grain  masses  are  visible 
in  the  unstained  section.  The  iodine  'reaction  is  given  best  in  the 
fresh  state,  but  is  also  often  successful  after  hardening. 

Some  of  the  amyloid  masses  lie  free  in  the  stroma,  but  most  are 
surrounded  by  connective-tissue  capsules.  They  vary  from  microscopic 
nodules  to  large  masses  easily  visible  with  the  naked  eye.  The  smaller 
ones  are  homogeneous,  often  with  a  few  nuclei ;  the  larger  are  generally 
convoluted,  with  clefts  and  fissures.  Amyloid  globules  are  seen  free  in 
the  tissue  and  also  enclosed  in  cells;  they  probably  do  not  originate 
in  the  cells,  but  are  taken  up  by  them  (Leber).  Lying  between  them 
in  the  fibrous  stroma  are  the  amyloid  and  hyaline  degenerated  blood- 
vessels. The  arteries  and  capillaries  show  most  change.  There  is 
endarteritis,  with  constriction  or  blocking  of  the  lumen,  the  intima 
being  thick,  rich  in  nuclei  and  fibres.  The  medium  is  enormously 
thickened,  homogeneous,  with  some  entangled  lymphocytes,  the  outer 
layers  being  made  up  of  thick  concentric  amyloid  scales.  The  capillary 
walls  are  thick  hyaline  or  amyloid  rings,  with  small  or  no  lumen.  The 
veins  are  least  altered. 

The  substance  is  also  found  deposited  in  the  lymphatic  spaces, 
which  then  form  beaded  cords,  the  constrictions  corresponding  with 
valves  in  the  lymph-vessels.  The  endothelium  is  usually  retained. 
Amyloid  substance  may  be  found  in  the  small  lymphatics  of  the  blood- 
vessel walls  (Hubner). 


102  THE    PATHOLOGY    OF   THE    EYE 

The  degenerative  changes  affect  other  unstriped  muscle-fibres 
besides  those  of  the  media  of  the  vessel  walls ;  e.  g.  Miiller's  muscle 
may  be  involved  (Vossius).  The  fibrous  tissue  itself  is  attacked,  the 
fibres  being  increased  to  three  or  four  times  their  normal  breadth, 
round,  rod,  or  spindle-shaped,  normal  or  degenerated,  nuclei  being 
scattered  amongst  them. 

The  final  stage  is  the  development  of  bone  in  the  amyloid  material. 
This  occurs  especially  in  the  neighbourhood  of  vessels.  Osteoblasts 
are  laid  down  upon  the  masses,  attacking  and  eroding  them. 
Calcium  salts  are  deposited,  and  finally  scales  of  true  bone,  with 
characteristic  bone-corpuscles,  are  formed.  Giant-cells  are  often  found 
applied  to  the  nodules. 

The  exact  rationale  of  the  formation  of  amyloid  masses  is  a  subject 
of  dispute,  which  belongs  rather  to  general  pathology,  and  cannot  be 
fully  entered  into  here.  Some  regard  the  process  as  taking  place 
essentially  in  the  lymphoid  cells,  the  affection  of  the  connective  tissue 
being  secondary  (v.  Recklinghausen,  Leber,  Raehlmann)  ;  others  look 
upon  the  cells  as  being  purely  passive  (Ziegler,  Birch-Hirschfeld, 
Vossius).  It  is  probable  that  the  change  occurs  in  inert  proteid 
exudates  and  secretions,  dominated,  however,  by  the  activity  of  the 
living  cells.  That  intra-cellular  hyaline  globules  also  occur  cannot, 
however,  be  denied. 

v.  RECKLINGHAUSEN. — Handb.  d.  allg.  Path,  des  Kreislaufs,  1883.  v.  OETTINGEN. — 
Dorpater  med.  Z.,  ii,  1871.  REYMOND. — Ann.  di  Ott.,  iv,  1874.  LEBER. — A.  f.  O.,  xix,  i, 
1873;  xxv,  i,  1879;  li,  i,  1900.  RAEHLMAXN. — Virchow's  Archiv,  Ixxxvii ;  A.  f.  A.,  x, 
1881.  *KUBLI—  A.  f.  A.,  x,  1881.  KAMOCKI—  C.  f.  A.,  x,  1886.  Vossius.— Ziegler's 
Beitrage,  iv,  1888;  v,  1889.  HUBNER. — B.  z.  A.,  xxxviii,  1899.  COLUCCI. — Ann.  di  Ott., 
xxix,  1900.  HERBERT. — T.  O.  S.,  xxii,  1902.  DIMMER. — Z.  f.  A.,  ix,  Erganzungsheft,  1903. 


XEROSIS 

Xerosis  of  the  conjunctiva  is  a  symptom  and  not  a  disease.  As 
its  name  implies,  it  is  characterised  by  dryness  of  the  conjunctiva. 
It  occurs  in  two  groups  of  cases  :  (i)  associated  with  general  disease; 
(2)  as  a  sequel  of  local  ocular  affection. 

The  first  type  occurs  in  two  forms  :  (a)  a  mild  form,  found  in 
adults,  accompanied  by  nyctalopia,  and  characterised  by  Bitofs  spots, 
small  triangular  patches  on  the  outer  and  inner  sides,  covered  by  a 
material  resembling  dried  foam,  which  is  not  wetted  by  the  tears  ; 
(b)  a  severe  form,  found  in  marasmic  children,  associated  with 
keratomalacia  and  necrosis  of  the  cornea.  Both  these  forms  pro- 
bably result  from  malnutrition. 

The  second  type  occurs  as  a  cicatricial  degeneration  of  the  con- 
junctiva— (a)  following  trachoma,  burns,  pemphigus,  diphtheria,  etc., 
commencing  in  isolated  spots,  ultimately  involving  the  whole  con- 
junctiva and  cornea;  (6)  following  exposure,  due  to  ectropion  or 
lagophthalmos. 

In  all  cases  the  principal  anatomical  changes  are  found  in  the 
epithelium,  which  becomes  thickened  and  epidermoid,  at  the  same 
time  undergoing  fatty  degeneration.  Leber  first  described  sections 


THE   CONJUNCTIVA  103 

through  the  whole  thickness  of  the  membrane.  The  superficial  cells 
are  flattened,  and  their  nuclei  have  disappeared  ;  the  deeper  layers 
consist  of  prickle-cells,  often  widely  separated  by  spaces  in  which 
leucocytes  are  found.  The  nuclei  of  these  cells  stain  well,  and  are 
surrounded  by  a  clear  zone,  outside  which  there  are  numerous  fat 
globules  ;  these,  however,  are  much  more  numerous  in  the  flattened 
cells.  Much  of  the  fat  is  due  to  the  secretion  of  the  Meibomian  glands, 
which  is  increased.  If  the  fat  is  removed  by  soap  the  cells  become 
capable  of  being  wetted  by  the  tears. 

The  surface  of  the  epithelium  is  for  the  most  part  even  ;  but  here 
and  there  the  deeper  cells  are  irregularly  clumped  together  and 
separated  from  their  neighbours,  and  these  balls  of  epithelium  often 
project  above  the  surface,  and  later  become  free  in  the  conjunctival 
sac  (Kuschbert).  They  contain  numerous  intra-  and  extra-cellular 
"  xerosis "  bacilli,  which  grow  rapidly  under  the  conditions  which 
exist,  but  are  not  the  cause  of  the  complaint. 

Baas  found  few  leucocytes  between  the  deeper  cells.  Changes  in 
the  protoplasm  and  nuclei  commenced  in  the  middle  layers.  The  pro- 
toplasm showed  uneven  staining — either  a  clear  or  a  deeply  stained 
zone  around  the  nucleus,  or  general  faint  staining ;  there  were  also 
vacuoles.  The  nuclei  stained  less  than  normal,  especially  at  the  peri- 
phery; in  other  cells  the  centre  was  less  stained,  so  that  the  nuclei 
assumed  the  signet-ring  form.  The  fat  globules  stained  deeply  with 
osmic  acid,  so  that  the  superficial  cells  often  became  filled  with  reduced 
osmium. 

Attention  has  more  recently  been  devoted  to  the  horny  changes 
which  take  place  in  the  more  superficial  cells  (Dotsch,  Basso).  Those 
slightly  below  the  surface  show  granules  in  the  cytoplasm  which 
stain  very  deeply  with  haematoxylin.  The  granules  consist  of  kera- 
tohyalin,  and  the  layer  in  every  respect  resembles  the  stratum 
granulosum  of  the  epidermis.  The  horny  cells  upon  the  surface  stain 
very  deeply  in  a  diffuse  manner,  showing  no  granules.  The  cells  here 
are  often  united  into  long  wavy  bands  or  lamellae  (Basso). 

This  epidermoid  condition  of  the  conjunctiva  has  been  called 
tyloma  conjunctives  by  Gallenga  and  Best.  It  probably  occurs  in  rare 
cases  as  a  congenital  malformation — the  simplest  type  of  dermoid  {see 
"  Epithelial  Plaques"). 

Keratohyalin,  besides  staining  deeply  with  haematoxylin,  also  stains 
by  Gram's  method,  differing  from  other  substances  in  retaining  the 
stain  when  treated  with  acid  alcohol  (Ernst).  It  also  stains  with 
Weigert's  fibrin  stain,  and  becomes  deep  blue  with  iron  haematoxylin 
(Apolant).  The  strong  affinity  for  haematoxylin  is  shown  by  Unna's 
method,  in  which  overstained  sections  are  differentiated  with  potassium 
permanganate  solution.  Keratohyalin  shows  the  red  fuchsin  stain  with 
van  Gieson's  method,  whereas  the  more  advanced  horny  material  in 
the  superficial  cells  stains  yellow. 

BITOT. — Gaz.  hebdomadaire,  1863.  LEBER. — A.  f.  O.,  xxix,  3,  1883.  KUSCHBERT. — 
Deutsche  med.  Woch.,  1884.  WEEKS. — A.  of  O.,  xv,  1886.  BAAS. — A.  f.  O.,  xl,  5,  1894. 
GALLENGA. — Ann.  di  Neuropath.,  1890.  SCHIMMELPFENNIG.  —  A.  f.  O.,  xliii,  1897. 
STEPHENSON. — T.  O.  S.,  xviii,  1898.  BEST. — B.  z.  A.,  xxxiv,  1899 ;  K.  M.  f.  A.,  xxxviii, 


104  THE    PATHOLOGY    OF   THE    EYE 

1900.     *DOTSCH. — A.  f.  O.,  xlix,  2,   1900.     BASSO. — Ann.  di  Ott,  xxix,  1900.  ERNST. — 

Arch.  f.  mikr.  Anat.,  xlvii ;  Ziegler's  Beitrage,  xxi.     APOLANT. — Arch.  f.  mikr.  Anat.,  Ivii, 
1901. 


PlNGUECULA 

Pinguecula  is  a  triangular  patch  on  the  conjunctiva,  found  usually 
in  elderly  people,  especially  those  exposed  to  dust,  etc.  It  occurs  in 
the  direction  of  the  palpebral  aperture,  the  apex  of  the  triangle  being 
directed  outwards.  It  affects  the  nasal  side  first  as  a  rule,  the  temporal 
later.  The  upper  border  is  a  little  above  the  horizontal  meridian  ; 
when  large,  the  inner  and  outer  pingueculae  may  meet  below  the  cornea, 
never  above.  It  has  been  seen  as  early  as  fifteen,  and  is  probably  very 
slow  in  development.  It  may  encroach  upon  the  cornea,  these  cases 
forming  early  stages  in  the  formation  of  pterygium.  It  is  greyish  in 
colour,  with  yellow  spots,  which  may  be  so  numerous  as  to  make  it 
appear  yellow  throughout.  The  spots  seen  with  a  loupe  are  of  irregular 
shape,  the  largest  and  most  deeply  coloured  being  often  at  the  edges. 
Isolated  spots  are  often  seen  beyond  the  edges. 

The  early  theories  and  investigations  are  of  historical  interest,  but 
are  often  inaccurate.  The  yellow  coloration  was  thought  to  be  due  to 
deposits  of  fat, — hence  the  name.  Weller  first  proved  this  was  not  so. 
Saemisch  described  a  thickening  of  the  epithelium,  fibrosis  of  the  sub- 
mucosa,  and  obliteration  of  vessels.  Robin  and  Alt  laid  stress  upon  the 
thickened  epithelium  ;  Seitz,  and  Wedl  and  Bock,  upon  the  fibrosis, 
Wedl  and  Bock  mentioning  the  formation  of  clumps  of  yellow  pigment. 
v.  Michel  described  proliferation  of  elastic  tissue,  the  tunica  propria  being 
infiltrated  by  a  colloid  material.  Vassaux  found  thinning  of  the  epithe- 
lium, with  patches  of  cornification,  and  colloid  deposits  in  the  stroma, 
which  did  not  give  an  amyloid  reaction.  Gallenga  pointed  out  the  pre- 
ference for  the  nasal  side,  and  found  thickening  of  the  epithelium,  with 
cornification.  The  deeper  layers  of  the  epithelium  and  the  stroma  con- 
tained pigment,  to  which  the  yellow  colour  was  ascribed.  This  obser- 
vation was  doubtless  due  to  the  fact  that  the  material  was  obtained 
from  dark  southern  races.  Proliferation  of  elastic  tissue  was  noted. 

Fuchs  made  an  exhaustive  examination  of  twenty  cases  derived 
from  the  cadaver ;  the  investigation  included  flat  and  teased  prepara- 
tions, as  well  as  serial  sections.  The  essential  changes  are  found  in 
the  substantia  propria,  and  consist  in  deposits  of  amorphous  hyaline 
material,  hyaline  degeneration  of  the  fibrous  tissue,  and  proliferation  of 
elastic  tissue. 

The  amorphous  hyaline  material  is  deposited  in  the  form  of  fine 
granules,  especially  in  the  superficial  layers.  They  lie  free  in  the  inter- 
fibrillar  spaces,  and  fuse  into  irregular  angular  grains.  The  grains  fuse 
into  irregular  nodules,  with  a  smoother  contour.  They  are  arranged  in 
places  along  the  walls  of  the  vessels,  which  may  have  also  undergone 
hyaline  degeneration ;  in  this  manner  a  radial  disposition  is  shown, 
often  marked  in  those  cases  which  extend  below  the  cornea.  The 
deposits  are  insoluble  in  strong  mineral  acids,  alkalies,  ether,  chloro- 
form, etc.  They  stain  deeply  with  alum  carmin,  eosin,  acid  fuchsin  : 


THE   CONJUNCTIVA  105 

only  the  larger  ones  are  stained  by  hasmatoxylin.  They  give  no 
amyloid  reaction.  They  are  therefore  allied  to  v.  Recklinghausen's 
"  hyalin."  The  nodules  often  fuse  into  larger  concretions,  which 
may  be  visible  with  the  naked  eye  (over  o'l  mm.).  The  largest  of 
these  only  stain  at  the  edges  with  haematoxylin.  They  seem  to 
approach  the  condition  of  amyloid,  staining  brown  with  Lugol's  solu- 
tion (iodine),  but  they  never  stain  pink  with  methyl  violet. 

The  loose  subconjunctival  fibrous  tissue  also  shows  hyaline  de- 
generation. The  fibres  become  thicker  and  more  homogeneous;  they 
also  grow  in  length  and  become  convoluted.  The  nuclei  are  often 
hidden,  but  not  degenerated.  The  degeneration  is  not  uniform,  but 
patchy.  Several  clumps  are  often  connected  by  a  strand,  which  may 
represent  a  degenerated  vessel.  They  are  often  covered  by  an  endo- 
thelial  membrane,  which  represents  the  normal  structure.  Deposits 
of  granules  take  place  in  parts  of  the  larger  clumps,  and  these  may 
go  on  to  form  concretions.  The  same  process  occurs  in  less  degree 
in  the  superficial  scleral  lamellae,  only  those  concentric  with  the  cornea 
being  usually  affected,  the  meridional  ones  escaping.  This  is  probably 
an  intercurrent  phenomenon,  having  nothing  to  do  with  pinguecula 
proper. 

Normally,  only  the  subconjunctival  (episcleral)  tissue  is  rich  in 
elastic  fibres.  In  pinguecula  these  are  increased  in  number,  in  calibre, 
and  in  length,  so  that  they  become  convoluted  and  form  knotty  heap 
They  proliferate  into  the  submucosa,  and  the  whole  thickness  of  the 
substantia  propria  may  be  pervaded  by  close  parallel  bands  of  elastic 
fibres.  The  convoluted  clumps  are  often  large  enough  to  be  seen  with 
the  naked  eye,  and  compose  one  form  of  the  yellow  spots.  The  more 
swollen  fibres  (over  0^03  mm.)  are  often  loosely  arranged,  and  break  up 
into  fragments  of  various  sizes  and  lengths.  Some  show  a  deeply 
stained  (hsematoxylin)  central  band,  with  a  lighter  irregular  sheath  ; 
others  are  longitudinally  fibrillated.  Hypertrophy  of  the  elastic  fibres 
not  only  pervades  the  conjunctiva  and  the  episclera,  but  also  the  surface 
layers  of  the  sclera.  Here  they  appear  as  spiral  or  convoluted  bands 
between  the  lamellae.  The  swollen  fibres  often  go  on  to  the  formation 
of  hyaline  concretions  as  well  as  the  white  fibres,  but  these  are  not  so 
frequent  or  so  large,  and  are  less  regularly  contoured. 

In  typical  sections  through  a  pinguecula  the  following  layers  can 
be  made  out,  though  often  not  in  a  single  section  : — (i)  Epithelium, 
(2)  submucosa,  (3)  pinguecula  proper,  (4)  layer  of  hyaline  fibrous 
tissue,  (5)  layer  of  loose  subconjunctival  tissue,  (6)  episclera,  (7)  sclera. 

i.  The  Epithelium. — This  is  modified  conjunctival  epithelium.  In 
the  depressions  it  may  be  quite  normal,  with  basal  cubical  cells  having 
deeply  stained  nuclei,  round  or  polygonal  cells  in  several  layers,  and 
superficial  cylindrical  cells.  On  the  eminences,  where  it  is  exposed  to 
the  pressure  of  the  lids,  the  epithelium  becomes  flattened,  and  may 
even  be  reduced  to  a  double  layer  of  flat  nucleated  spindle-shaped  cells. 
The  smaller  depressions  are  filled  in  with  epithelium,  the  surface  re- 
maining smooth  (levelling  tendency  of  epithelium  [Fuchs]).  Cornifica- 
tion  is  excessively  rare.  Pigment  may  be  present  as  in  normal  con- 
junctiva, but  is  not  increased.  "Colloid  degeneration"  (de  Vincentiis), 


106  THE    PATHOLOGY    OF   THE    EYE 

i.  e.  vacuolation  of  the  cells  and  their  nuclei,  may  occur  as  in  ptery- 
gium  (q.  v.),  and  may  affect  all  the  cells  except  the  basal  ones.  Con- 
cretions may  invade  the  epithelium,  which  is  thinned  over  them  and 
may  be  destroyed.  They  are  not  formed  in  situ.  Psorosperms  may  be 
present  (Fuchs). 

2.  Submucosa. — This  is  normal  at  a  short  distance  from  the  limbus, 
consisting  of  wavy  fibrous  tissue  with  many  cells  and  vessels.    Near  the 
cornea  it  is  thin  and  very  dense,  showing  only  a  delicate  striation,  with 
very  few  cells  and  no  blood-vessels.     It  is  raised  en  masse  into  waves  by 
the  underlying  nodules.     The  submucosa  and  the  next  layer  tend  to 
invaginate  the  cornea,  so  that  the  epithelium  or  the  superficial  corneal 
laminae,  or  both,  are  invaded.     This  forms  the  earliest  development  of 
the  pterygium. 

3.  The  Pinguecula  Proper. — This  consists  of  a  thick  mass  with  irre- 
gular surface,  containing  scarcely  any  nuclei  or  vessels.     Under  a  low 
power  it  looks  homogeneous  ;  under  a  higher  power  it  is  seen  to  consist 
of  dense  bands  of  fibrous  tissue.,  mostly  running  meridionally,  but  with 
areas  of  circular   fibres  cut  across.      Amongst   these  are   embedded 
masses  of  hyaline  deposits,  hyaline  and  elastic  fibres,  and  concretions. 

4.  Layer  of  Hyaline  Fibrous  Tissue. — This  runs  chiefly  meridionally, 
with  nodules  of  hyaline  fibres  cut  across  here  and  there. 

5.  Layer  of  Loose  Subconjunctival  Tissue. — This  shows  in  places  the 
changes  from  which  the  nodules  are  later  developed,  viz.  fine  granules 
and  small  nodules,  with  thickened  elastic  fibres. 

6.  Episclera,  with  small  knots  of  enlarged  elastic  fibres. 

7.  Solera,  with  hypertrophied  elastic  fibres,  and  occasionally  hyaline 
lamellae. 

The  changes,  therefore,  are  essentially  degenerative,  and  are  attribu- 
table to  prolonged  irritation  by  dust,  smoke,  etc.,  and  age.  More  recent 
observations  by  Sgrosso,  Hiibner,  and  others,  confirm  the  facts  brought 
forward  by  Fuchs.  Sgrosso  distinguishes  an  episcleral  and  a  conjunc- 
tival  pinguecula,  the  latter  being  further  subdivided  into  epithelial  and 
fibrous,  the  last  named  being  the  commonest.  Hiibner  lays  more  stress 
upon  the  elastic  fibres,  which  were  demonstrated  by  the  Tanzer-Unna 
orcein  method,  than  upon  the  hyaline  degeneration.  The  elastic  tissue 
showed  degeneration  allied  to  that  found  by  Unna  and  others  in  the 
skin.  There  can  be  little  doubt  that  the  increase  in  elastic  tissue  is 
the  main  cause  of  the  yellow  colour  in  pinguecula,  and  is  the  essentia 
element. 

WELLER. — Die  Krankheiten  des  menschl.  Auges,  Berlin,  1822.  SAEMISCH. — G.-S.,  iv, 
1876.  ALT. — Lectures  on  the  Human  Eye,  p.  57,  New  York,  1880.  WEDL  AND  BOCK. — 
Path.  Anat.  des  Auges,  p.  59,  Wien,  1886.  v.  MICHEL. — Lehrb.  der  Augenheilk.,  p.  196,  1890. 
VASSAUX. — Comptes  rendus  de  la  Soc.  de  Biol.,  p.  432,  1886.  GALLENGA. — Giornale  d.  R. 
Accad.  di  Med.,  Torino,  1888.  *FUCHS. — A.  f.  O.,  xxxvii,  3,  1891.  SGROSSO. — Atti  di  R. 
Accad.  Med.-Chir.  di  Napoli,  xlix.  *HUBNER. — A.  f.  A.,  xxxvi,  1898. 


PTERYGIUM 

Pterygium  is  a  peculiar  encroachment  of  the  conjunctiva  upon  the 
cornea.     It  is  triangular  in  shape,  and  when  single    is  always  upon 


THE    CONJUNCTIVA  107 

the  nasal  side.  When  double,  the  temporal  one  has  developed  later. 
It  is  derived  from  pinguecula,  and  therefore  only  occurs  in  the  situa- 
tions mentioned.  It  must  be  carefully  distinguished  from  the  pseudo- 
pterygium,  a  fold  of  conjunctiva  adherent  to  the  cornea,  which  has 
been  previously  ulcerated.  The  latter  may  occur  at  any  part  of  the 
cornea;  the  conjunctiva  forms  a  bridge  over  the  limbus,  and  a  fine 
sound  can  always  be  passed  beneath  it.  This  is  not  possible  with  a 
true  pterygium. 

The  apex  of  the  pterygium  is  usually  blunt,  the  classical  description 
of  a  sharp  apex  applying  only  to  rare  cases.  This  anterior  border 
generally  slopes  from  up  and  in  to  down  and  out,  and  is  irregular. 
There  is  no  ulcer  in  the  cornea  beyond  it,  as  formerly  described,  but 
there  are  often  small  opacities,  which  gradually  fuse  with  the  edge  and 
partly  cause  its  irregularity.  The  anterior  border  has  a  grey,  gelatinous 
margin,  and  is  often  as  much  as  i  mm.  thick ;  the  numerous  vessels  of 
the  pterygium  do  not  enter  this  part.  Sometimes  it  is  nearly  flat  and 
star-like  ;  these  are  probably  stationary  pterygia.  There  are  two  main 
folds  at  the  upper  and  lower  borders  of  the  pterygium,  diverging  as 
they  pass  away  from  the  cornea.  These  are  due  to  the  traction  upon 
the  conjunctiva,  and  in  advanced  cases  are  multiplied  by  subsidiary 
folds.  There  is  no  passage  beneath  the  neck  at  the  limbus,  but  only 
pockets  above  and  below,  so  that  the  pterygium  is  a  single  layer  of 
conjunctiva,  and  is  adherent  in  its  whole  length  to  the  sclerotic  and 
cornea,  though  only  loosely,  except  at  the  apex.  The  area  of  adhesion 
to  the  cornea  is  always  smaller  than  the  breadth  of  the  head,  but  is 
very  irregular.  The  traction  on  the  conjunctiva  often  pulls  the  plica 
semilunaris  out  of  place,  so  that  its  upper  end  is  pulled  outwards,  and  it 
may  even  lie  horizontally.  It  is  recognisable  as  a  deep  red  line. 
There  are  often  yellow  spots  in  the  pterygium,  but  always  fewer  than 
in  a  pinguecula.  Cysts  may  be  visible  rarely,  usually  in  the  head, 
never  in  the  grey  zone. 

The  earlier  histological  investigations  are  merely  of  historical 
interest,  as  they  are  frequently  inaccurate,  having  been  made  upon 
excised  fragments.  Getz  found  inflammatory  changes.  Winther 
regarded  the  pterygium  as  an  overgrowth  of  corneal  tissue.  Schreiber 
thought  it  was  covered  on  the  deep  surface  with  epithelium  and  was 
due  to  an  adherent  polypous  growth  of  the  conjunctiva.  Arlt, 
Goldzieher,  Poncet,  Harder,  and  Gallenga  examined  pterygia  still 
attached  to  the  globe.  Their  results  are  contradictory.  Mannhardt 
regarded  episcleritis  as  the  starting-point,  but  he  also  described  the 
gradual  encroachment  of  pinguecula  upon  the  cornea.  Zehender  first 
derived  pterygium  from  pinguecula,  but  gave  no  proofs.  Arlt  considered 
it  to  be  a  mere  fold  of  conjunctiva,  adherent  to  a  marginal  ulcer.  If 
this  were  so  it  should  be  common  in  children  after  phlyctenular 
conjunctivitis.  An  ulcer  was  described  as  present  beyond  the  tip  of  the 
fold,  and  as  it  advanced  across  the  cornea  the  fold  of  conjunctiva  was 
dragged  after  it. 

The  histology  of  pterygium  has  been  worked  out  very  fully  by 
Fuchs,  and  the  following  is  a  resume  of  his  paper : 

The  pterygium  is  covered  by  conjunctival  epithelium  for  the  greater 


io8 


THE    PATHOLOGY    OF   THE    EYE 


part  of  its  surface  (Fig.  54).  It  differs  much  in  thickness,  being  thin 
on  the  exposed  parts  and  thick  where  small  irregularities  in  the  stroma 
are  filled  in.  It  is  stratified,  with  flat  cells  upon  the  surface,  but  these 
become  cylindrical  in  the  folds  and  furrows,  and  also  where  the  normal 
conjunctiva  is  approached,  i.e.  away  from  the  apex.  Where  pig- 
mentation is  normally  present,  as  in  dark  people,  it  is  increased, 
especially  in  the  basal  cells,  but  it  may  occur  in  all  the  layers  as  well 
as  in  the  stroma.  In  the  middle  layers  there  are  often  intercalated 
stellate  cells,  whose  nuclei  and  protoplasm  stain  more  deeply  than  the 
others.  They  have  single  round  nuclei  and  ample  cytoplasm,  so  they 
ar.e  not  leucocytes  (Fuchs).  Rarely  there  are  hyaline  nodules  in  the 
epithelium,  and  also  psorosperm-like  cells.  The  latter  are  commonest 
in  the  furrows.  Some  of  the  cells  show  vacuolation  of  the  nuclei 


FIG.  54. — PTERYGIUM.      x   100. 

Small  pterygium  on  inner  side  of  cornea,  from  a  man  aged  75.  Note  hyaline 
degeneration  and  granular  deposits  in  fibrous  tissue  to  the  left.  The  new  tissue  is 
as  yet  entirely  superficial  to  Bowman's  membrane,  which  can  be  faintly  traced  in 
the  figure. 

("  colloid  degeneration "),  the  chromatin  being  pressed  down  into  a 
crescent  at  the  lower  border.  Goblet-cells  are  numerous,  especially  in 
the  depressions.  True  new-formed  glands  are  usually,  though  not 
invariably,  present.  They  occur  only  in  the  body  of  the  pterygium, 
some  millimetres  from  the  limbus.  They  are  tubular  depressions,  lined 
with  cylindrical  cells,  upon  a  basis  of  flattened  epithelial  cells.  The 
inner  layer  is  often  full  of  goblet-cells.  The  tubules  often  run 
horizontally  under  the  epithelium  and  branch  ;  they  may  be  surrounded 
by  lymphocytic  infiltration,  but  this  is  often  conspicuously  absent  in 
all  parts.  Sebaceous  glands  and  hair-follicles  may  be  found  in  the 
base,  but  these  belong  to  the  caruncle,  which  has  been  pulled  outwards. 
Cysts  may  be  formed  out  of  any  of  the  glands  or  depressions,  and  often 
contain  secretion  and  debris.  The  transition  from  conjunctival  to 


THE    CONJUNCTIVA  109 

corneal  epithelium  is  much  sharper  than  normal  at  the  apex  of  the 
pterygium.  In  most  cases  it  is  covered  by  corneal  epithelium,  in  some 
the  conjunctival  extends  a  short  distance  over  the  cornea,  and  this  is 
the  rule  for  the  sides.  Occasionally  the  limit  between  the  epithelia  is 
vertical,  but  often  the  conjunctival  thins  off  over  the  corneal,  and  is 
quite  distinguishable  from  it  by  the  cells  being  smaller  and  more 
deeply  stained.  The  corneal  epithelium  is  often  thickened  at  the 
margin. 

The  stroma  is  loose  and  rich  in  cells.  It  differs  only  from  normal 
conjunctiva  in  that  the  fibres  are  drawn  out  by  the  traction,  and  run 
parallel  instead  of  in  waves.  At  the  anterior  border  it  may  be  either 
loose,  cellular,  and  rich  in  vessels,  or  dense  and  firmly  fused  with  the 
cornea.  The  denser  apex  moves  forwards  as  the  pterygium  grows, 
leaving  looser  tissue  behind  it.  Patches  of  hyaline  degeneration  of  the 
fibres  and  vessel  walls  occur  as  in  pinguecula,  but  are  much  less  evident. 
Masses  of  enlarged  elastic  fibres  may  also  be  present. 

Bowman's  membrane  is  either  completely  destroyed  under  the 
pterygium,  or  is  only  present  in  fragments.  It  is  always  destroyed  for 
some  distance  beyond  the  apex  in  young  pterygia  (as  much  as  3  mm. 
[Fuchs] )  ;  in  the  oldest  it  stops  exactly  at  the  apex,  or  extends  a 
short  distance  under  or  into  the  apex.  Farther  from  the  apex,  where 
Bowman's  membrane  is  still  intact,  there  are  changes  which  are  seen 
with  the  loupe  as  islands  of  opacity.  Here  Bowman's  membrane  may 
be  destroyed  over  a  small  area,  and  be  replaced  by  loose  lamellae  with 
a  few  nuclei.  The  basal  epithelial  cells  generally  lie  obliquely  here, 
bending  over  towards  the  defective  spot.  Or  a  small  mass  of  dense 
fibrous  tissue,  with  long  nuclei,  may  lie  above  or  below  Bowman's 
membrane,  forming  a  depression  in  it  without  completely  destroying  it. 
Where  Bowman's  membrane  stops  it  may  be  cut  off  straight  or 
obliquely,  or  be  pointed,  or  break  up  into  fibres.  It  is  not  infrequently 
bent  round  or  folded.  There  are  always  fragments  of  Bowman's  mem- 
brane found  under  a  large  pterygium. 

When  the  anterior  border  of  the  pterygium  consists  of  loose  tissue 
it  always  penetrates  amongst  the  superficial  corneal  lamellae.  Some 
of  these  are  raised  up,  so  that  they  curve  forwards  or  may  even  turn 
back  in  the  opposite  direction.  They  are  finer  than  normal,  and  have 
clefts  between  them.  They  are  also  more  cellular,  and  may  be  infil- 
trated with  round-cells.  They  may  be  much  folded  and  bent,  and  if 
Bowman's  membrane  is  present  it  follows  the  curve,  or  the  lamellae 
may  bend  over  the  end  of  it,  so  that  they  come  to  lie  in  front.  This 
may  also  occur  at  the  sides  and  beneath  the  pterygium.  When  the 
anterior  border  consists  of  dense  fibrous  tissue  it  pushes  its  way 
between  the  epithelium  and  Bowman's  membrane,  here  and  there 
encroaching  upon  the  latter.  The  corneal  lamellae  are  here  little 
altered.  This  type  probably  represents  the  stationary  pterygium, 
whilst  the  other  is  progressive.  Both  types  occur  in  the  same  anterior 
border,  but  growth  is  often  unequal  in  different  parts. 

These  anatomical  characteristics  quite  disprove  Arlt's  view  that 
pterygium  is  caused  by  adhesion  of  conjunctiva  to  a  progressive  ulcer, 
and  is  gradually  drawn  forwards  as  the  ulcer  cicatrises  behind.  It 


no  THE    PATHOLOGY    OF   THE    EYE 

seems  probable  that  it  is  due  to  altered  nutrition  in  the  cornea,  due  to 
the  presence  of  a  pinguecula,  combined  probably  with  some  chemical 
changes  which  manifest  themselves  in  advance  of  the  apex  of  the  actual 
pterygium,  and  lead  to  tissue  changes  (histiolysis)  there.  The  pingue- 
cula doubtless  impedes  the  flow  of  blood  in  the  vessels  of  the  limbus, 
and  may  lead  to  local  atrophy  of  the  marginal  network. 

Recurrent  pterygium  shows  the  same  structure  as  primary  (Bocchi). 

Hiibner's  researches  on  forty  pterygia  confirm  those  of  Fuchs ;  but 
more  stress  is  laid  upon  the  presence  and  degenerative  changes  of  the 
elastic  tissue,  as  seen  by  the  orcei'n  method.  Sections  stained  by  acid 
orcei'n  and  van  Gieson  show  the  distribution  of  the  white  and  yellow 
fibrous  tissue  well.  Hiibner  considers  pterygium  independent  of 
pinguecula,  though  both  may  occur  together. 

ARLT. — Die  Krankheiten  des  Auges,  i,  1854.  ZEHENDER. — Handb.  der  ges.  Augen- 
heilk.,  1869.  SCHREIBER. — Inaug.  Diss.,  Leipzig,  1872.  POWER. — St.  Bart.'s  Hosp.  Rep., 
1875.  GOLDZIEHER. — C.  f.  A.,  ii,  1878.  PONCET. — A.  d'O.,  i,  1881 .  HARDER. — Mittheil.  aus 
der  k.  Univ.-Augenkl.  zu  Munchen,  i,  1882.  MANNHARDT. — A.  f.  O.,  xxii,  i,  1876.  GAL- 
LENGA. — Giorn.  d.  R.  Accad.  di  Med.,  Torino,  1888.  *FucHS. — A.  f.  O.,  xxxviii,  2,  1892. 
BOCCHI. — Arch,  di  Ott.,  ii,  1894.  *HUBNER. — A.  f.  A.,  xxxvi,  1897.  TRAPESONTZIAN. — 
A.  d'O.,  xxi,  1902. 


PIGMENTATION 

Spots  and  patches  of  pigment  occur  normally  at  the  limbus  in  dark- 
coloured  races,  and  in  them,  too,  the  epithelium  contains  pigment 
granules,  especially  in  the  deeper  layers,  and  there  are  more  chromato- 
phores  in  the  subconjunctival  tissue  than  in  the  fair  races.  In  dark 
races  the  pigment  also  occurs  in  branching  cells  amongst  the  epithelial 
and  subepithelial  cells. 

Pigmented  spots  in  the  conjunctiva  in  the  white  races  are  always 
suggestive  of  malignant  disease  (v.  infra).  Diffuse  pigmentation  occurs 
very  rarely,  and  is  apt  to  spread.  It  may  terminate  in  death  from 
melanotic  sarcoma  in  other  organs,  but  whether  the  conjunctival 
melanosis  is  primary  or  secondary  is  undecided.  In  one  case  which  I 
examined  the  patient  was  apparently  healthy,  apart  from  increasing 
pigmentation  of  the  conjunctiva  and  cornea.  On  microscopic  exa- 
mination the  pigment  formed  clumps  almost  entirely  confined  to  the 
epithelium  ;  there  were  a  few  masses  just  below  the  epithelium  in 
the  conjunctiva.  The  pigment  contained  no  iron,  and  was  readily 
bleached. 


ARGYROSIS 

Argyrosis  of  the  conjunctiva  has  been  examined  microscopically  by 
Junge,  Knies,  Hoppe,  and  others;  Frommann,  Riemer,  and  Neumann 
investigated  particularly  pigmentation  following  prolonged  internal 
administration  of  silver  nitrate.  The  anatomical  results  are  similar, 
whether  due  to  internal  or  external  use. 

Hoppe  found  the  pigmentation  greatest  in  the  lower  and  middle 


THE    CONJUNCTIVA  in 

third  of  the  conjunctival  sac  ;  the  intermarginal  zone  at  the  edge  of 
the  lid  was  normal ;  the  lower  punctum  was  more  deeply  stained  than 
the  upper. 

Microscopically  the  coloration  is  chiefly  due  to  staining  of  the 
elastic  fibres,  which  are  beautifully  demonstrated ;  less  to  pigment  free 
in  the  tissues.  The  pigment  is  everywhere  in  the  form  of  extremely 
fine  black  granules.  The  granules  separate  out  on  treatment  with 
concentrated  hydrochloric  acid,  and  become  yellow  and  highly  re- 
fractile ;  on  addition  of  ammonium  sulphide  they  become  black  from 
the  formation  of  silver  sulphide.  The  granules  are  decolourised  by 
concentrated  nitric  acid ;  they  remain  unaltered  with  caustic  potash, 
though  the  fibres  swell  up.  The  pigment  is  dissolved  by  potassium 
cyanide,  and  decolourised,  with  the  formation  of  silver  iodide,  by  iodine 
solution. 

The  granules  therefore  consist  of  an  almost  insoluble  ground 
substance,  \vith  a  superficial  black  deposit.  Hoppe  found  none 
intra-cellular,  so  that  leucocytes  apparently  play  no  part  in  carrying 
the  pigment.  It  seems  to  ensheath  the  elastic  fibres,  without  entering 
into  any  chemical  combination  ;  some  fibres  remain  unaltered,  as 
shown  by  Weigert's  elastic  stain. 

There  is  a  thin,  nearly  continuous  layer  of  free  pigment  immediately 
under  the  epithelium  of  the  palpebral  conjunctiva;  this  is  absent  in 
the  bulbar  conjunctiva,  where  the  free  pigment  pervades  the  tissues 
uniformly  like  an  emulsion. 

The  adventitia  of  the  vessels  is  free  from  staining,  whilst  the  pig- 
ment is  dusted  over  the  media,  lying  thickly  in  the  cement  substance 
between  the  muscle-fibres  ;  in  this  manner  transverse  stripes  are 
marked  out.  In  the  capillaries  the  pigment  is  deposited  in  the  cement 
substance  between  the  endothelial  cells. 

The  epithelium  is  free  from  pigment.  The  elastic  fibres  are  seen 
to  be  arranged  in  a  superficial  layer  of  large  bundles,  running  mostly 
vertical  to  the  surface,  and  a  deep  layer  of  fine  fibres,  forming  a  dense 
network. 

JUNGE. — A.  f.  O.,  v,  2,  1859.  FROMMANN. — Virchow's  Archiv,  xvii,  1859.  RIEMER. — 
Arch.  f.  Heilkunde,  xvi,  1875.  NEUMANN. — Strieker's  Med.  Jahrb.,  1877.  KNIES. — K.  M. 
f.  A.,  xviii,  1880.  *HOPPE. — A.  f.  O.,  xlviii,  3,  1899. 


CYSTS 

Small  cysts  of  the  conjunctiva  are  not  very  rare,  and  probably  often 
escape  detection.  Out  of  sixty-five  published  cases,  five  were  in  the 
C.  palpebrarum,  nineteen  in  the  fornix,  thirty-two  in  the  C.  bulbi,  and 
nine  elsewhere  (Ballaban).  They  arise  from  a  great  variety  of  causes, 
and  the  exact  pathology  of  many  of  them  is  disputed.  Cirincione  has 
recently  published  a  monograph  upon  the  subject,  in  which  the  following 
classification  is  adopted: — I,  Congenital  cysts;  II,  Acquired  cysts; 
III,  Lymphatic  cysts;  IV,  Parasitic  cysts;  V,  Traumatic  cysts. 
Groups  III,  IV,  and  V  really  belong  to  Group  II,  but  are  separated 


ii2  THE    PATHOLOGY    OF   THE    EYE 

on  account  of  their  importance.  The  acquired  cysts  are  further 
divided  into  superficial  and  deep.  The  superficial  cysts  are  sub- 
divided as  follows : — (i)  Cysts  with  transparent  contents  (serous 
cysts),  including  (a)  cysts  of  the  fornix,  (b)  cysts  of  the  C.  bulbi ;  (2) 
cysts  with  opaque  contents  ;  (3)  cysts  containing  bacteria  ;  (4)  false 
cysts.  The  deep  cysts  include  (i)  cysts  of  Krause's  glands ;  (2) 
parasitic  cysts  (cysticercus,  filaria). 

This  classification  seems  unnecessarily  complicated.  I  shall  con- 
sider cysts  of  the  conjunctiva  under  the  headings  (i)  Traumatic, 
(2)  Retention,  (3)  Lymphatic,  (4)  Pseudo-cysts,  (5)  Parasitic,  (6)  Con- 
genital. The  term  "  serous  cyst"  is  better  avoided  ;  it  usually  includes 
lymphatic  and  some  retention  cysts. 

BALLABAN. — A.  f.  A.,  xliii,  1901.  *CIRINCIONE. — B.  z.  A.,  lv,  1903.  POSSEK. — Z.  f.  A., 
ix,  Erganzungsheft,  1903  (Bibliography). 

TRAUMATIC  CYSTS 

Cysts  occasionally  develop  in  the  conjunctiva  after  injury,  especially 
at  the  site  of  tenotomy  wounds,  or  around  foreign  bodies.  These  are 
implantation  cysts,  due  to  the  inclusion  of  epithelium,  which  subse- 
quently grows,  degenerates  in  the  centre,  and  forms  a  cyst.  Only  three 
such  cases  have  been  submitted  to  careful  histological  examination 
(Uhthoff,  Treacher  Collins).  In  one  the  cyst  appeared  five  weeks  after 
a  strabismus  operation,  in  a  woman  of  twenty ;  in  another  five  weeks 
after  a  wound  which  perforated  the  upper  lid  and  injured  the  globe. 
In  each  the  cyst  was  lined  by  stratified  epithelium.  In  one  there  were 
several  cilia,  partly  fixed,  partly  loose,  some  projecting  outside.  The 
epithelium  had  proliferated  around  them  inside  the  cyst.  Treacher 
Collins's  case  was  a  boy  aged  nine,  whose  eye  was  wounded  by  a 
screw-driver  at  the  age  of  nine  months.  There  was  a  scar  vertically 
across  the  inner  part  of  the  cornea,  and  a  cyst  just  beyond  the  limbus 
below.  The  latter  was  found  to  lie  between  the  conjunctiva  and  the 
sclerotic,  not  communicating  with  the  anterior  chamber.  It  was  lined 
with  laminated  epithelium. 

These  cysts  are  generally  fixed  to  the  sclerotic  by  inflammatory 
tissue,  and  cannot  be  moved  so  freely  as  the  lymphatic  cysts.  Like 
them,  however,  they  contain  a  simple  serous  fluid. 

Cirincione  doubts  the  existence  of  traumatic  cysts.  In  one  case 
which  he  examined  he  found  a  cysticercus.  • 

UHTHOFF. — Berl.  klin.  Woch.,  1879.  TREACHER  COLLINS. — Researches,  London,  1896. 
LOPEZ. — A.  f.  O.,  xxi,  1892.  LANGE. — K.  M.  f.  A.,  xli,  1903. 

RETENTION  CYSTS 

Retention  cysts  in  the  conjunctiva  are  usually  small,  developed  in 
new-formed  glands,  the  result  of  inflammatory  processes,  and  in  the 
so-called  Henle's  glands  ;  they  also  occur  rarely  in  Krause's  glands. 

As  has  been  mentioned,  Henle's  glands  are  really  folds  in  the  con- 
junctiva, but  true  tubular  glands  are  occasionally  present,  and  are 


THE   CONJUNCTIVA  113 

certainly  developed  by  inflammatory  processes.  Moreover  every 
mucous  membrane,  apart  from  goblet-cells,  is  a  secreting  surface,  and 
when  it  is  swollen  and  inflamed  the  depressions  are  liable  to  be  shut 
off  from  the  surface  by  the  apposition  of  the  folds.  The  secretion  is 
increased  by  the  inflammation,  and  the  goblet-cells  are  multiplied. 
The  mucus  and  serous  fluid  are  retained,  and  give  rise  to  cysts. 
Originally  tubular,  with  many  diverticula,  especially  in  the  fornix,  the 
glands  become  dilated  and  globular,  or  polyhedral  from  mutual  pres- 
sure. The  walls,  like  the  surface,  are  formed  of  a  double  layer  of 
epithelium,  the  inner  layer  being  cylindrical  with  the  nuclei  towards 
the  bases  of  the  cells.  But  this  regularity  is  not  maintained.  The 
pathological  processes  lead  to  proliferation  and  degeneration  of  the 
cells.  In  parts  the  epithelium  is  heaped  up  ;  in  others  the  pressure  of 
the  retained  secretion  is  more  felt,  and  flattening  of  the  cells  occurs. 
The  goblet-cells  are  often  much  increased  in  numbers,  so  that  the 
lumina  are  lined  with  them.  Other  cells  become  osdematous,  often 
become  loosened  from  their  attachments  and  lie  free  in  the  cavity, 
there  to  undergo  further  degenerative  changes.  The  retained  fluids 
and  debris  alter  chemically,  and  often  form  concretions  (q.  v.). 

These  cysts  have  been  studied  by  Rogman,  Ginsberg,  Fuchs, 
Wintersteiner,  Stoewer,  and  others.  In  Rogman's  case  the  epithelium 
varied  from  two  to  eight  layers,  and  formed  many  papillary  ingrowths 
into  the  lumen.  Ballaban  describes  cysts  in  the  conjunctiva  which  he 
attributes  to  degeneration  of  the  central  cells  in  solid  downgrowths  of 
epithelium  (Fig.  34).  The  process  was  evident  in  the  younger  columns, 
the  cells  showing  vacuolation ;  later,  hyaline  concretions  were  formed. 
The  fully  developed  cysts  were  lined  with  a  varying  number  of  rows  of 
cells,  the  larger  the  cyst  the  greater  being  the  degeneration  and  the 
thinner  the  epithelial  lining. 

Less  aberrant  are  the  cysts  of  Krause's  glands.  These  have  been 
especially  studied  by  de  Vincentiis  and  his  pupils.  Wintersteiner 
regards  the  cases  of  Gallenga,  de  Vincentiis,  Moauro,  Antonelli,  and 
Stoewer  as  genuine  ;  those  of  Rombolotti,  Bull,  Camuset,  and  Rampoldi 
and  Faravelli  as  doubtful.  They  are  generally  small,  and  lie  in  the 
upper  or  lower  fornix ;  hence  they  cannot  be  due  to  Waldeyer's  glands. 
The  cysts  are  evidently  formed  in  a  tubular  gland  with  many  convolu- 
tions, so  that  they  cannot  be  due  to  Henle's  glands  ;  moreover  they  lie 
deeper.  The  lining  epithelium  varies,  being  cylindrical  in  the  more 
normal  parts,  flattened  and  pathologically  altered  in  other  parts.  It 
may  form  a  single  or  a  double  layer,  but  the  surface  epithelium  often 
proliferates  and  forms  several  layers,  the  inner  cells  being  loose  and 
free  in  the  lumen. 

The  cysts  often  form  in  part  of  the  duct,  which  normally  has  a 
double  layer  of  epithelium,  the  inner  layer  being  cubical.  Sometimes 
only  part  of  the  duct  is  cystic  ;  there  is  then  a  triangular  depression, 
forming  the  mouth,  at  the  conjunctival  surface.  The  acini  in  con- 
nection with  the  cystic  duct  generally  atrophy.  Each  cyst  is  unilocular, 
but  several  may  be  present,  and  a  single  one  may  give  the  appearance 
of  many  when  the  walls  are  collapsed  and  folded.  Concretions  with 
giant-cells  occurred  in  Wintersteiner's  case.  As  there  was  no  break  in 


ii4  THE    PATHOLOGY    OF   THE    EYE 

the  epithelium  and  no  granulation  tissue,  the  giant-cells  must  have 
been  formed  either  from  leucocytes  or  from  epithelial  cells,  either  by 
nuclear  division  or  by  confluence  of  cells.  Antonelli  also  found  con- 
cretions, in  his  case  derived  from  blood-corpuscles. 

The  relative  infrequency  of  cysts  of  Krause's  glands  is  to  be  attri- 
buted to  the  fluidity  of  their  secretion  (Ischreyt),  and  to  their  slight 
powers  of  resistance  (Wolfring).  Blocking  of  the  ducts  is  apparently 
due  to  cicatricial  contraction  from  injury  (Rombolotti),  trachoma 
(Moauro,  Wintersteiner),  and  inflammatory  infiltration  (Ischreyt).  In 
many  cases  the  conjunctiva  was  otherwise  normal. 

Another  case  reported  by  Wintersteiner,  and  others  by  Vossius, 
Rampoldi  and  Faravelli,  etc.,  would  seem  to  be  developed  in  con- 
genital atypical  glands. 

The  cysts  which  occur  in  old  trachomatous  granulations  are  really 
retention  cysts  in  new-formed  glands  (v.  p.  69). 

Cirincione  found  the  superficial  cysts  of  the  fornix  to  be  either  uni- 
or  multi-locular ;  they  might  be  as  large  as  a  small  bean.  The  wall 
consisted  of  a  structureless  membrane  lined  by  a  double  layer  of 
epithelium.  The  inner  layer  varied  greatly,  consisting  in  some  cases 
of  cubical  cells  with  round  nuclei  and  little  protoplasm,  in  others  of 
cells  in  which  the  cell  body  seemed  to  be  replaced  by  a  hyaline  drop, 
the  nucleus  being  pressed  towards  the  base.  The  outer  layers  of  cells 
were  flattened,  with  round,  more  deeply  staining  nuclei.  The  cubical 
cells  were  absent  in  the  large  cysts,  and  often  in  places  elsewhere. 
The  contents  of  the  cysts  varied  greatly,  being  generally  hyaline,  often 
granular.  The  substance  consists  of  the  mucus  secreted  by  the  goblet- 
cells,  mixed  with  cell  detritus.  Some  cysts  contained  small  brown 
granules,  which  were  probably  reduced  silver,  the  result  of  treatment 
with  silver  nitrate.  Others  contained  curious  ovoid  bodies,  with  double 
contour,  from  15  ju  to  50  /n  in  diameter,  containing  a  nucleus-like  body. 
They  were  probably  degenerated  cells ;  the  possibility  of  their  being 
parasites  was  considered. 

Cirincione  denies  the  new  formation  of  true  glandular  depressions 
in  the  conjunctiva  in  inflammatory  conditions,  supporting  his  contention 
on  the  absence  of  such  an  occurrence  elsewhere  in  the  body.  On  the 
other  hand,  by  means  of  an  exhaustive  research  by  serial  sections,  he 
found  a  few  true  crypt-like  glands  in  the  conjunctiva  of  a  seven  and  a 
half  months'  foetus,  the  ordinary  folds  and  furrows  being  absent  at  this 
age. 

Cirincione  found  serous  cysts  of  the  bulbar  conjunctiva  much  rarer 
than  those  of  the  fornix,  if  lymphatic  cysts  are  eliminated.  They  were 
never  more  than  3  mm.  in  diameter,  and  lay  rather  deep,  about  half- 
way between  the  surface  and  the  sclerotic.  There  was  usually  only  a 
single  layer  of  flattened  epithelium.  In  spite  of  Cirincione's  opinion, 
it  would  seem  likely  that  these  were  really  lymphatic  cysts. 

Cirincione  found  superficial  opaque  cysts  of  the  conjunctiva  in 
subacute  trachoma.  They  were  small,  ovoid,  ash-grey,  generally 
situated  at  the  convex  border  of  the  tarsus.  They  are  apparent!}' 
due  to  degeneration  of  the  acini  of  Krause's  glands.  The  stroma  is  at 
first  densely  infiltrated  with  round-cells  ;  the  duct  loses  its  epithelium 


THE    CONJUNCTIVA  115 

in  patches.  Later,  the  gland-cells  swell  and  show  hyaline  degenera- 
tion, running  together  and  losing  their  definite  contours,  until  the 
parenchyma  becomes  transformed  into  a  transparent  mass,  containing 
nuclei  and  a  few  recognisable  acini.  Finally  a  cystic  space  is  formed, 
lined  with  a  double  layer  of  epithelium,  inner  cylindrical  and  outer 
cubical,  resembling  the  lining  of  the  ducts.  It  contains  a  granular 
mass  consisting  of  degenerated  cells  and  debris. 

Cirincione  only  found  bacteria  in  small  round  cysts,  about  the  size 
of  a  pin's  head,  near  the  posterior  border  of  the  tarsus.  They  were 
greenish  and  opaque.  They  contained  very  small  micrococci,  rarely 
bacilli.  The  organisms  stained  best  by  Gram's  method.  The  cysts 
were  formed  from  conjunctival  crypts  ;  they  contained  many  cells,  and 
were  surrounded  by  inflammatory  infiltration.  They  were  lined  with 
enormous  goblet-cells  lying  on  a  layer  of  flattened  cells. 

Cirincione  calls  "  false  cysts  "  those  which  are  formed  in  chronic 
inflammatory  conditions  amongst  the  folds  and  papillary  outgrowths 
of  the  conjunctiva.  The  false  papillae  are  often  pressed  together  so 
that  secretion  is  retained  in  the  depressions  between  them.  These 
are  not  true  cysts,  since  the  depressions  are  not  true  glands. 
They  are  never  larger  than  a  pin's  head,  contain  secretion,  cellular 
debris  and  leucocytes,  and  are  rarely  lined  with  cubical  epithelium. 
Cirincione  considers  that  the  cysts  in  old  trachomatous  lids  originate 
from  such  false  cysts.  It  is  probable  that  many  are  retention  cysts  of  the 
Meibomian  and  other  glands,  following  cicatrisation  around  the  ducts. 

Cirincione's  "  deep  cysts  "  are  retention  cysts  of  Krause's  glands. 
They  are  found  chiefly  at  the  lateral  parts  of  the  fornices,  are  smooth- 
walled  and  oval,  with  the  long  axis  transverse.  They  are  most  common 
in  young  people,  with  trachoma  or  chronic  catarrh. 

The  cysts  are  lined  with  a  double  layer  of  epithelium,  inner  cubical 
or  cylindrical,  outer  flattened.  In  the  more  distended  parts  or  cysts 
there  is  only  a  single  layer  of  flattened  cells.  The  neighbouring  acini 
vary,  some  being  normal,  others  compressed  by  the  cystic  condition  of 
the  duct,  or  themselves  dilated  into  cysts. 

ROGMAN. — A.  d'O.,  xv,  1895.     GINSBERG. — A.  f.  O.,  xliv,   i,  1897.     FUCHS. — A.  f.  O., 

Xlvi,     I,     1898.       WlXTERSTEINER. A.    f.    O.,    xlvi,     2,    1898.       SlOEWER. A.    f.    O.,    liv,   1902. 

BALLABAN. — A.  f.  A.,  xliii,  1901.  RAMPOLDI  AND  FARAVELLI. — Ann.  di  Ott.,  xvii,  1888. 
MOAURO. — Ann.  di  Ott.,  xviii,  p.  251,  1889.  ANTONELLI. — Ann.  di  Ott.,  xix,  1890.  ROMBO- 
LOTTI. — A.  f.  A.,  xxxi,  1895.  MAKROCKI. — K.  M.  f.  A.,  xxi,  1883.  STOEWER. — K.  M.  f.  A., 
xxx,  1892.  ISCHREYT. — A.  f.  A.,  xxxv,  1897.  BULL. — Amer.  Jl.  of  Med.  Sc.,  1878. 
Vossius. — B.  d.  o.  G.,  1896.  WOLFRING. — VII  internat.  Kongr.,  Heidelberg,  1888. 

ACKERMANN. A.  f.  A.,  xlvi,   1902.       *  ClRINCIONE. B.  Z.  A.,  Iv,    1903. 

LYMPHATIC  CYSTS 

Lymphatic  cysts  cannot  be  pathologically  differentiated  from 
lymphangiectasis  and  lymphangioma  (q.  v.),  but  are  locally  exaggerated 
manifestations  of  the  same  condition.  They  are  confined  to  the 
C.  bulbi.  In  the  intermediate  stages  certain  of  the  dilated  lymph- 
spaces  become  much  enlarged,  and  the  fluid  cannot  be  pressed  from 
these  into  the  smaller  ones.  Later,  these  develop  into  true  cysts, 
which  may  be  sessile  or  pedunculated,  are  yellowish  and  transparent, 


n6  THE    PATHOLOGY   OF   THE    EYE 

and  vary  in  size,  but  are  never  very  large.  They  grow  partly  by  the 
fusion  of  smaller  dilatations.  They  differ  from  the  epithelial  serous 
cysts  in  not  being  definitely  oval  or  round,  and  in  never  being  single. 
Even  when  they  are  apparently  single  clinically,  they  are  found  to  be 
multilocular  on  examination.  The  large  cyst  reported  by  Snell  and 
described  by  Treacher  Collins  would  appear  to  be  an  exception  to  this 
rule,  but  the  fact  that  it  was  present  from  birth  makes  its  true  nature 
doubtful.  It  was  lined  throughout  by  a  single  layer  of  endothelial 
cells. 

Histologically  these  cysts  have  the  same  structure  as  the  lymphan- 
giomatous  spaces. 

PRIESTLEY  SMITH. — Brit.  Med.  Jl.,  1883.  SNELL. — T.  O.  S.,  xviii,  1898.  SGROSSO. — 
Ann.  di  Ott.,  xxxi,  1902. 

PSEUDO-CYSTS 

In  addition  to  the  "  false  cysts  "  described  by  Cirincione  (v.  p.  115), 
there  are  others,  of  which  the  following  are  examples  : 

Goy  describes  a  large  congenital  serous  cyst  in  a  woman  of  fifty-nine, 
occurring  in  conjunction  with  other  congenital  malformations  of  the 
eye.  It  was  not  a  lymphatic  cyst,  but  probably  a  pseudo-cyst  developed 
from  symblepharon.  It  was  lined  with  stratified  epithelium,  and 
encroached  upon  the  cornea. 

Subconjunctival  haematomata  have  been  accredited  with  the 
formation  of  serous  cysts.  Mitvalski  describes  a  case  of  this  kind,  in 
which  subconjunctival  haemorrhage  occurred  after  vomiting.  In  four- 
teen days  there  developed  an  oval,  elastic  cyst,  the  size  of  a  bean, 
containing  clear  fluid,  the  walls  only  being  infiltrated  with  blood. 
These  consisted  of  fibrous  tissue,  and  there  was  no  endothelial  or 
epithelial  lining. 

GOY. — B.  z.  A.,  xxxix,  1899.     MITVALSKI. — C.  f.  A.,  xvii,  1893. 


PARASITIC  CYSTS 

Parasitic  cysts  of  the  conjunctiva  are  rare,  and  are  due  to  varieties 
of  cysticercus,  C.  cellulosse  (that  of  tsenia  solium)  being  commonest. 
Others  are  caused  by  filariae.  The  hydatid  cyst,  due  to  tsenia 
echinococcus,  occurs  in  the  orbit,  and  may  appear  as  a  subconjunctival 
cyst. 

Cysticercus. — The  first  observation  was  reported  by  Baum,  in  1838, 
and  since  then  fifty-five  cases  have  been  recorded  (Lagrange),  or  one 
sixth  of  all  cases  of  intra-ocular  cysticercus  (Ballaban).  Mackenzie 
reported  two,  one  borrowed  from  Estlin  and  seen  at  the  Bristol  Eye 
Infirmary  ;  others  have  been  published  by  Canton,  Vernon,  Werner, 
Seeker  Walker,  etc.,  in  England.  It  is  commoner  in  Germany  and 
Russia.  It  is  much  less  common  in  the  conjunctiva  than  in  the 
vitreous  (v.  Graefe,  Poncet).  It  generally  occurs  in  young  patients. 

Conjunctival  cysticercus  appears  as  a  hemispherical  or  oval  cyst, 
usually  at  the  internal  angle  in  the  lower  fornix;  but  there  are  many 


THE    CONJUNCTIVA  117 

exceptions  to  this  situation.  Sgrosso  found  it  at  the  outer  angle, 
Meyer  below  the  cornea,  Rohmer  in  the  upper  fornix.  It  is  adherent 
to  the  sclerotic  by  an  inflammatory  capsule,  which  surrounds  it,  and  is 
formed  of  two  layers  (Makrocki).  The  inner,  adherent  to  the  cysti- 
cercus,  is  made  up  of  embryonic  cells ;  the  outer  of  fusiform  cells,  with 
foreign-body  giant-cells  (Gallemaert,  Fuchs).  Histological  examina- 
tions have  been  made  by  Binet  and  Fieuzal,  Jani,  Mitvalsky,  Cirincione, 
etc.;  and  Sgrosso  inoculated  the  parasite  into  the  rabbit's  orbit  and 
obtained  similar  results.  Bull  gives  good  photographs  of  the  booklets 
and  cyst  wall. 

The  cyst  is  pink,  almost  transparent  in  the  centre,  in  which  there 
is  usually  seen  a  whitish  or  yellow  disc,  which  is  the  site  of  the  scolex. 
There  may  be  some  conjunctival  reaction,  but  this  is  often  slight. 

The  cyst  contains,  besides  the  parasite,  fluid  excreted  by  it.  The 
lluid  contains  proteids  andleucomains  (Mourson  and  Schlagdenhaufen), 
and  produces  acute  peritonitis  when  injected  into  the  abdominal  cavity 
of  rabbits. 

Filaria. — Filaria  loa  occurs  in  residents  in  the  West  Coast  of  Africa, 
and  not  infrequently  finds  its  way  under  the  conjunctiva  (Wilson, 
Argyll-Robertson,  Gerwais  and  v.  Beneden,  Hirschberg,  Ludwig).  It 
apparently  does  not  lead  to  the  formation  of  cysts.  An  allied  species, 
Filaria  inermis  (Grassi),  was  found  in  a  cyst  by  Cirincione.  The  cyst 
walls  resembed  very  nearly  those  of  the  cysticercus  cyst. 

BAUM. — Ann.'  d'Oc.,  ii,  1839.  MACKENZIE. — Diseases  of  the  Eye,  1839.  ESTLIN. — 
Med.  Times  and  Gaz.,  1838.  CANTON. — Lancet,  1848.  VERNON. — R.  L.  O.  H.  Rep.,  vi,  4, 
1869.  *  WERNER.— T.  <S.  S.,  ix,  1889.  SECKER  WALKER.— T.  O.  S.,  xvi,  1896.  v.  GRAEFE. 
— A.  f.  O.,  iii,  2,  1857.  PONCET. — Gaz.  med.  de  Paris,  1874.  SGROSSO. — Rev.  gen.  d'O., 
xii,  1893.  MAKROCKI. — K.  M.  f.  A.,  xxi,  1883.  GALLEMAERT. — Bull.  Acad.  roy.de  Med.  de 
Belgique,  Bruxelles,  1897.  FIEUZAL. — Bull,  de  la  Clinique  des  Quinze-vingts,  1886.  JANI. 
— K.  M.  f.  A.,  xxi,  1883.  FUCHS. — K.  M.  f.  A.,  xv,  1877.  MITVALSKY. — C.  f.  A.,  xvii,  1893. 
BULL. — T.  Am.  O.  S.,  1899.  *  KRAEMER. — Die  tierischen  Schmarotzer  des  Auges,  in  G.-S., 
x,  1899.  CIRINCIONE. — B.  z.  A.,  Iv,  1903.  WILSON. — T.  Am.  O.  S.,  1890.  ARGYLL- 
ROBERTSON. — T.  O.  S.,  xv,  1895 ;  xvii,  1897.  GERWAIS  AND  v.  BENEDEN. — Traite  de  Zool. 
med.,  ii.  HIRSCHBERG. — C.  f.  A.,  xx,  1896.  LUDWIG. — Z.  f.  wiss.  Zool.,  Ix,  1895. 

CONGENITAL  CYSTS 

Small  cysts  occur  in  some  congenital  tumours,  especially  naevi  (q.  v.). 

More  important  are  the  peculiar  cysts  of  the  lower  fornix  associated 
with  maldevelopment  of  the  eyeball  (microphthalmia,  etc.).  These 
will  be  described  in  connection  with  congenital  malformations. 


TUMOURS 
POLYPUS 

There  is  a  tendency  for  all  tumours  of  the  conjunctiva  to  assume 
the  polypoid  form,  and  hence  several  quite  different  pathological  condi- 
tions have  been  called  polypi.  They  are  doubtless  moulded  to  this 
shape  chiefly  by  the  movements  of  the  lids  and  eyes  (Axenfeld),  and 


n8 


THE    PATHOLOGY    OF   THE    EYE 


the  direction  of  least  resistance  to  growth  is  outwards.  True  polypus, 
i.  e.  hyperplasia  of  a  circumscribed  portion  of  the  conjunctiva  in  all  its 
layers,  is  said  to  be  unknown  (Elschnig).  So-called  polypi  are  either 
true  papillomata,  soft  or  hard  fibromata,  or  granulation-tissue  tumours 
(granulomata) ;  though  other  growths,  e.  g.  sarcomata,  often  become 
polypoid  ;  even  dermoids  may  be  polypoid  (v.  infra). 


*  ELSCHNIG. — A.  f.  A.,  xix. 


ZIMMERMANN. — K.  M.  f.  A.,  xxxii,  1894. 


PAPILLOMA 

Papilloma  of  the  conjunctiva  is  found  most  commonly  at  the  inner 
canthus  in  the  neighbourhood  of  the  caruncle  and  plica  semilunaris. 
It  is  also  found  in  the  fornices,  and  Colucci  has  described  a  case  in 
which  it  invaded  the  whole  length  of  all  four  fornices.  The  small, 


FIG.  55. — PAPILLOMA  OF  THE  CONJUNCTIVA,      x  9. 

The  leaflets  are  composed  almost  entirely  of  epithelium,  with  a  fine  core  of 
fibrous  tissue.  The  growth  came  from  near  the  caruncle,  and  in  the  centre  of  the 
lower  part  some  acini  of  a  sebaceous  gland  are  seen.  See  also  Fig.  81. 

raspberry-like  tumours  are  also  often  multiple.  They  are  very  prone  to 
recur  after  removal.  They  occur  at  all  ages.  In  some  cases  they  are 
small,  multiple,  and  very  vascular,  the  vessels  being  arranged  in  a  star- 
shaped  manner  (Burnett).  I  have  seen  a  good  example  of  this  type ; 
the  small  growths  have  some  resemblance  to  limpet  shells. 

Histologically  papillomata  consist  of  a  central  core  of  fibrous  tissue 
with  blood-vessels,  covered  by  stratified  epithelium  (Fig.  55).  Gradations 
are  met  with  between  papillomata  with  very  little  fibrous  tissue  and 
fibromata  with  papillae  upon  the  surface,  and  various  parts  of  the  same 
tumour  may  show  these  peculiarities.  The  epithelium  is  generally 


THE    CONJUNCTIVA  119 

greatly  increased  in  thickness,  so  that  it  makes  up  the  main  mass  of 
the  tumour,  the  supporting  connective  tissue  being  reduced  to  a 
minimum.  Many  of  the  cells,  especially  upon  the  surface,  are 
often  goblet-cells  ;  the  whole  surface  was  covered  with  them  in  a 
case  reported  by  Wagenmann.  The  blood-vessels  are  usually  very 
thin-walled,  often  merely  endothelial  tubes  ;  they  are  usually  widely 
dilated.  The  fibrous  tissue  may  be  actually  reduced  to  a  few  strands 
around  the  vessels.  The  papillae  often  divide  and  subdivide,  forming  a 
very  complicated  mass  of  leaflets. 

As  elsewhere  in  the  body,  papillomata  grow  outwards  and  do  not 
usually  invade  the  deeper  tissues,  but  there  can  be  no  doubt  that  they 
sometimes  become  malignant.  Examples  have  been  published  by 
Lagrange  and  Mazet,  Kopetzky  v.  Rechtperg,  and  Altland,  in  which 
papillomata  later  invaded  the  globe  and  became  intra-ocular.  These 
cases  are  rare ;  epitheliomata  with  papillomatous  proliferation  are 
commoner  ;  both  are  generally  in  elderly  people.  Papillomata,  as  well 
as  epithelioma  (v.  infra),  occur  in  xeroderma  pigmentosum  (Sims). 

Even  when  very  efflorescent,  these  growths  usually  only  cover  the 
cornea  ;  in  the  rare  cases  in  which  it  is  involved,  the  growth  begins 
between  the  epithelium  and  Bowman's  membrane  (Caspar).  In 
Lambert's  case,  in  which  the  tumour  grew  from  the  limbus,  it  was 
partially  attached  to  the  cornea.  In  Altland's  cases  there  had  been 
episcleritis  ;  the  author  discusses  the  aetiological  importance  of  injury 
and  inflammation,  as  well  as  the  question  of  malignancy. 

de  Schweinitz  gives  good  drawings  of  a  papilloma  growing  from  the 
plica  semilunaris. 

HlRSCHBERG  AND  BlRNBACHER. C.  f.  A.,  viii,   1884.       PARISOTTI. ReC.  d'Ophth.,   1884. 

MAGNUS. — K.  M.  f.  A.,  xxv,  1887.  ELSCHNIG. — A.  f.  A.,  xix,  1889.  FUCHS,  S. — A.  f.  A., 
xx,  1889.  RUMSCHEWITSCH. — K.  M.  f.  A.,  xxix,  1891 ;  A.  f.  A.,  xxxiv,  1898.  CASPAR. — 
A.  f.  A.,  xxiv,  1892.  SIMS. — A.  of  O.,  xxi,  i,  1892.  WAGENMANN. — A.  f.  O.,  xl,  2,  1894. 
ZIMMERMAXX. — K.  M.  f.  A.,  xxxii,  1894.  COGGIX. — A.  of  O.,  xxiii,  1894.  JESSOP. — 
T.  O.  S.,  xvi,  1896.  STEINER. — A.  d'O.,  xvi,  1896.  WEEKS. — New  York  Eye  Infirmary  Rep., 
1896.  STUELP. — C.  f.  A.,  xxi,  1897.  BURNETT. — T.  Am.  O.  S.,  1897.  LAGRANGE  AND 
MAZET.— Ann.  d'Oc.,  cxix,  1898.  GRUNERT. — K.  M.  f.  A.,  xxxvii,  1899.  COLUCCI. — Ann. 
di  Ott,  xxviii,  2,  1899.  DE  SCHWEINITZ. — T.  Am.  O.  S.,  1900..  *  KOPETZKY  v.  RECHTPERG. 
— A.  f.  O.,  Ii,  1900.  LAMBERT. — T.  Am.  O.  S.,  1901.  ALTLAND. — A.  f.  A.,  xliv,  1901. 
KOERBER. — Z.  f.  A.,  x,  1903. 


SIMPLE  GRANULOMA 

Simple  granulation-tissue  tumours  occur  frequently  as  the  result  of 
irritation,  ulceration,  or  injury.  They  are  particularly  common  in 
chalazia  which  have  broken  through  the  conjunctiva  or  have  been 
incompletely  dealt  with,  and  in  tenotomy  wounds.  They  may  be 
sessile  or  definitely  polypoid. 

Microscopically  they  are  typical  granulation  tissue  (Fig.  56),  with 
its  great  variety  of  cells,  amongst  which  all  kinds  of  leucocytes, 
endothelial  cells,  giant-cells,  and  young  connective-tissue  cells  are 
found  (Figs.  57,  58).  They  are  richly  pervaded  by  very  thin-walled  new 
vessels,  and  haemorrhages  are  common.  It  may  not  be  easy  to  dis- 
tinguish them  from  inflamed  capillary  naevi.  They  are  usually  un- 


I2O 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  56. — SIMPLE  GRANULOMA  OF  THE  CONJUNCTIVA,      x  55. 
The  growth  consists  of  extremely  vascular  tissue,  partly  covered  by  epithelium. 
It  is  made  up  of  round  and  polygonal  cells,  many  of  which  are  epitheiioid ;   others 
are  lymphocytes,  and  there  are  a  few  polymorphonuclear  leucocytes. 


.- 

*-*f'     -     —      '">*'  .     "*»- 


FIG.  57. — SIMPLE  GRANULOMA  OF  THE  CONJUNCTIVA,      x   180. 
Another  part  of  the  same  specimen  more  highly  magnified,  showing  very  large, 
swollen,  epitheiioid  cells. 


THE    CONJUNCTIVA  121 

covered  by  epithelium,  but  layers  of  rapidly  growing  epithelium  often 
partially  cover  the  peripheral  parts,  and  islets  of  epithelium  are  often 
enclosed,  especially  near  the  surface  (Fig.  58). 

They  often  bleed,  being  a  cause  of  "  bloody  tears,"  and  they  also 
drop  off  as  the  result  of  the  movements  of  the  lids. 

Simple  granulomata  may  reach  a  large  size  and  project  between  the 
lids,  which  partially  strangle  the  pedicle.  The  head  is  then  cedematous, 
and  the  microscopical  characters  are  not  unlike  those  of  myxomatous 
tissue.  Moreover  the  epithelium  covering  the  surface  dips  into  every 
crevice  of  the  granulation  tissue,  so  that  the  appearance  of  epithelioma 
may  be  simulated  (cf.  case  reported  by  Hartridge). 

Granulation   tissue   often    accumulates   around   embedded   foreign 


FIG.  58. — SIMPLE  GRANULOMA  OF  THE  CONJUNCTIVA,      x   120. 
Showing  the  epithelium  invading  every  crevice  of  the  irregular  surface  of  the 
growth,  passing  downwards  in  places  for  a  considerable  distance.     There  are  many 
red  corpuscles  and  polymorphonuclear  leucocytes. 

bodies.  One  such  case  is  reported  by  Uhthoff;  the  patient  was  a 
stonemason,  and  had  a  small  growth  on  the  conjunctiva  which  was 
taken  for  a  melanotic  sarcoma.  Examination  showed  it  to  consist  of 
granulation  tissue  with  giant-cells,  developed  around  quartz  particles 
which  gave  an  iron  reaction. 

HARTRIDGE. — T.   O.   S.,  xxii,  1902.     UHTHOFF. — Verhandl.  der  Natiirforscher,  Nurem- 
berg, 1893. 


LYMPHOMA 

Lymphomata  belong  to  the  ill-defined  group  of  round-celled  tumours, 
which  doubtless  represent  very  different  pathological  conditions  (v.  p.  18). 


122 


THE    PATHOLOGY   OF   THE    EYE 


They  occur  in  leukaemic  and  allied  conditions,  and  consist  of  mononuclear 
round-cells  embedded  in  wide-meshed,  fine  connective  tissue,  with 
relatively  few  vessels.  They  also  contain  numerous  endothelial  cells, 
with  large  faintly  staining  nuclei.  It  has  been  described  in  the  plica 
semilunaris  (Koerber). 

Lymphosarcoma  is  not  easily  distinguished  anatomically  from 
simple  lymphoma.  It  has  also  been  described  in  the  plica  semilunaris 
(v.  infra). 

LEBER. — A.  f.  O.,  xxiv,  i,  1878.  AXENFELD. — A.  f.  O.,  xxxvii,  4,  1891.  BERL. — B.  z.  A., 
xxxvii,  1899.  KOERBER. — Z.  f.  A.,  x,  1903. 


FIBROMA 

The  typical  "  polypus,"  growing  from  the  fornix,  is  usually  a  fibroma. 
It  is  distinguished  from  the  papilloma  in  having  a  smooth  surface,  but 


FIG.  59. — FIBROMA  OF  THE  CONJUNCTIVA,      x    10. 

The  growth  was  taken  from  a  socket.     Note  the  true  papillae  on  the  surface. 
The  epithelium  contains  goblet-cells  in  places. 

this  requires  care  in  observation,  as  the  moist,  swollen  papillae  often 
seem  fused  together,  Fibromata  also  occur  at  the  canthi,  usually  the 
inner,  growing  from  the  plica  semilunaris.  They  are  mostly  soft,  but 
the  consistency  varies  with  the  amount  and  character  of  the  fibrous 
tissue. 

Soft  fibromata  grow  rapidly,  are  very  vascular,  and  readily  bleed, 
both  internally,  giving  rise  to  deposits  of  blood-pigment,  and  externally, 
causing  "  bloody  tears."  They  consist  of  masses  of  fibrous  tissue,  chiefly 
arranged  in  longitudinal  bundles  (Fig.  59),  covered  by  conjunctival 
epithelium  of  about  the  normal  thickness.  They  contain  many  oval 


THE   CONJUNCTIVA 


123 


, 


and    spindle-shaped     young     connective-tissue    cells,    and    are    often 

infiltrated  with  lymphocytes  and  polymorphonuclear  leucocytes,  which 

also  invade  the  epithelium.     The  fibrous  tissue  is  frequently  cedematous, 

probably  due  to  the  pressure  of  the 

lids   upon   the   pedicle,    the    tumours 

being   often    large.     Hence    they   are 

sometimes    described    as    myxofibro- 

mata,  probably  a  misnomer  (Fig.  60) 

(Morton).     They  may  be  covered  by 

thickened    epithelium,    so    that    some 

resemblance  to  papilloma  is  brought 

about  (Rumschewitsch). 

Hard  fibromata  consist  of  com- 
pacter  fibrous  tissue,  with  very  few 
connective-tissue  cells  and  few  ves- 
sels. They  are  also  covered  by  rather 
thin  epithelium,  and  this  is  often 
arranged  upon  true  papillae,  the  surface 
being  smooth.  They  occur  principally 

,.   ,  .  •;.  r,  J.J  FIG.  DO. FlBRO-MYXOMA    OF    PLICA 

on    the   lid   conjunctiva    and    on    the  SEMILUNARIS. 

caruncle,    and  do   not   usually  recur   SO        After    Morton    and    Treacher    Collins 

readily    after    removal     as     the    soft  (T.  O.  S.,  x,  pi.  vi).    From  one  of  the 

form.  tumours,  showing  myxomatous  structure 

Fibromata  were  carefully  described 

by  Mackenzie,  and  their  pathological  position  was  determined  more 
recently  by  Elschnig. 

A  telangiectatic  fibroma  from  the  plica  semilunaris  has  been 
reported  by  Paderstein.  It  followed  an  injury  by  a  twig,  and  consisted 
of  soft,  cellular  fibrous  tissue,  with  a  hyaline  capsule  and  hyaline 
deposits.  It  was  very  vascular. 

MACKENZIE. — Diseases  of  the  Eye.  ELSCHNIG. — A.  f.  A.,  xix,  1889.  MORTON. — 
T.  O.  S.,  x,  1890.  ISCHREYT. — A.  f.  A.,  xxxii,  1896.  RUMSCHEWITSCH. — A.  f.  A.,  xxxvi, 
1898.  PADERSTEIN.— A.  f.  A.,  xliii,  1901. 


H^EMANGIOMA 

Haemangiomataare  either  capillary  (angioma.  [Virchow])  or  cavernous. 
They  occur  most  commonly  in  children  (before  the  twentieth  year  in 
twenty-nine  cases  out  of  forty-four  [Pergens] ),  arid  are  often  congenital. 
The  plica  semilunaris  is  most  affected,  but  they  also  occur  in  all  parts. 

Histologically  they  consist  of  convoluted  capillaries,  with  very  little 
interstitial  tissue.  When  this  is  increased  they  are  called  angiofibro- 
mata,  and  all  grades  between  these  and  soft  fibromata  occur.  Angio- 
sarcomata  also  occur,  but  here  the  sarcomatous  condition  is  the  essential 
feature.  In  some  cases  dilatations  occur,  filled  with  blood,  forming 
cavernous  angiomata,  but  these  are  rarer  (Fig.  61).  The  vesse  s 
involved  may  be  either  conjunctival,  scleral,  muscular,  or  orbital. 

In  twenty-one  cases  the  distribution  and  nature  of  the  angiomata 
were  as  follows  : — (i)  From  the  globe — four  angiofibromata,  four 
cavernous,  one  mixed  ;  (2)  from  the  plica — one  simple,  one  cavernous 


I24 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  61. — CAVERNOUS  ANGIOMA.     x  55. 

From  an  encapsuled  growth,  the  size  of  an  almond,  in  the  lower fornix.  Large 
venous  sinuses,  lined  with  endothelium  and  filled  with  red  corpuscles,  are  seen. 
The  structure  is  identical  with  that  of  normal  erectile  tissue. 


FlG.    62. H^MANGIOMA    OR    BLOOD-CYST.        X     IJ, 

The  spaces  are  lined  with  endothelium  and  contain  many  red  corpuscles.  The 
dark  triangular  projection  on  the  right  below  consists  of  a  mass  of  dilated  capillaries 
packed  with  red  corpuscles.  The  epithelium  over  the  convex  surface  is  corneous. 


THE   CONJUNCTIVA  125 

(3)  from  the  caruncle — one  angiofibroma ;  (4)  from  the  fornix — two 
cavernous  angiomata,  one  cavernous  fibro-angioma  ;  (5)  from  the  lid  — 
two  simple,  one  cavernous,  one  fibro-angioma,  two  cavernous  fibro- 
angiomata  (Pergens). 

Capillary  angiomata  (telangiectases)  vary  in  shape,  being  round  or 
elongated,  with  smooth  or  irregular  surface. 

In  Eversbusch's  and  Alt's  cases  numerous  acinous  glands  were 
present,  the  plica  being  affected ;  in  Reis's  case,  which  was  near  the 
limbus,  there  were  cystic  spaces  and  nests  of  epithelium.  It  is  possible 
that  some  are  developed  in  pure  congenital  naevi.  Paderstein  describes 
a  telangiectatic  fibroma  from  the  plica  (v.  infra).  Parts  of  the  same 
tumour  may  be  capillary  and  cavernous. 

Cavernous  angiomata  may  be  polypoid  (Rampoldi  and  Steffanini, 
Kroschinsky),  but  commonly  form  rounded  tumours,  which  can  be 
partially  emptied  of  blood  by  pressure  and  position  of  the  body  (Fig.  61) . 
The  spaces  are  lined  with  a  single  layer  of  endothelium,  and  are 
separated  by  a  network  of  bands  of  fibrous  tissue,  which  may  be  very 
cellular,  or  hyaline.  They  contain  many  wide  vessels.  The  spaces 
contain  masses  of  red  corpuscles,  or  fibrinous  coagula,  or  hyaline 
exudates.  Fehr  and  Burnett  have  found  calculi  like  those  met  with 
in  varicose  veins.  They  are  seen,  after  decalcification,  to  consist  of 
concentric  layers  of  hyaline  material,  merging  into  fibrous  tissue  peri- 
pherally. Sometimes  striated  muscle  is  found  in  the  fibrous  tissue 
between  the  spaces;  these  angiomata  probably  originated  in  the  muscle 
and  invaded  the  conjunctiva  secondarily. 

Angiomata  are  usually  benign ;  some  grow  rapidly,  others  remain 
stationary  or  commence  suddenly  to  grow. 

Telangiectatic  sarcoma  of  the  plica  semilunaris  has  been  reported 
by  del  Monte. 

WARDROP. — Essays  on  the  Morbid  Anatomy  of  the  Eye,  Edinburgh,  1808;  On  Fungus 
Haematodes,  Edinburgh,  1809.  LEBER. — A.  f.  O.,  xxvi,  3,  1880.  HORROCKS. — T.  O.  S.,  iii, 

1883.  EVERSBUSCH. — B.  d.  o.  G.,    1883.     RAMPOLDI  AND  STEFFANINI. —Ann.  di  Ott.,  xiii, 

1884.  SNELL. — T.  O.  S.,  xiii,  1893.     KROSCHINSKY. —B.  z.  A.,  xiv,    1894.     ALT. — Amer. 
Jl.    of  O.,  xii,   1895.     LIPPINCOTT. — T.  Am.   O.  S.,    1895.    FEHR. — A.  f.  O.,  xliv,  3,  1897. 
BURNETT. — A.  of  O.,  xxvi,  1897.    REIS. — K.  M.  f.  A.,  xxxviii,  1900.    *  PERGENS. — K.  M.  f.  A., 
xxxix,  1901.     PADERSTEIN. — A.  f.  A.,  xliii,  1901.     AHLSTROM. — B.  z.  A.,  liv,  1902. 


LYMPHANGIOMA 

Dilatations  of  the  lymphatics  of  the  conjunctiva  have  been  studied 
by  Steudener  (1874),  Irnre  (1876),  Laskiewicz  (1877),  Bull  (1878), 
Delecceuillerie  (1892),  and  others.  They  occur  in  three  forms,  which 
cannot  be  dogmatically  separated,  viz.  lymphangiectasis,  lymphan- 
gioma,  and  lymphatic  cysts. 

Lymphangiectasis. — Small  dilatations  of  the  lymphatics  of  the  con- 
junctiva are  of  common  occurrence.  They  are  rarely  larger  than  a 
pin's  head,  are  often  arranged  like  rows  of  pearls,  and  contain  clear 
fluid.  Microscopically  they  resemble  the  dilated  lymphatics  found  in 
many  inflammatory  conditions,  e.  g.  episcleritis.  The  endothelium  is 
intact,  and  the  vessels  contain  granular  or  hyaline  coagulum  with  a 


126 


THE    PATHOLOGY   OF   THE    EYE 


few  leucocytes.  By  injury  they  may  become  filled  with  blood,  and  a 
permanent  communication  with  a  blood-vessel  may  follow  (lyuiphectasia 
hczmorrhagica  [Leber]).  Zimmermann  has  recorded  such  a  case. 

Lymphangioma. — Large  cavernous  dilatations  of  the  lymphatics  are 
rare.  Uhthoff  described  a  small  unilocular  cyst.  More  frequently  there 
is  a  system  of  cavities,  separated  by  thin  septa  (Fig.  63).  These  are 
composed  of  fibrous  tissue  and  are  lined  by  endothelium.  The  con- 
junctival  stroma  is  pressed  apart.  Such  cases  have  been  reported  by 
Alt,  Jocqs,  Snell,  etc.  Nettleship  gives  a  good  drawing  of  a  lymphatic 
"  nsevus."  I  have  examined  a  very  extensive  lymphangioma,  in  which 
the  whole  conjunctival  sac  was  involved. 

This  case  nearly  resembles  one  very  fully  reported  by  Meyerhof, 


FIG.  63. — LYMPHANGIOMA  OF  CONJUNCTIVA,      x  55. 

Note  goblet-cells  in  epithelium,  which  is  more  highly  magnified  in  Fig.  16.  The 
adenoid  layer  below  is  infiltrated.  The  spaces  are  dilated  lymph  spaces,  lined  by 
endothelium  ;  many  contain  hyaline  material.  See  MacCallan,  T.  O.  S.,  xxiii,  1903. 

and  the  appearance  of  the  boy  was  very  like  that  shown  in  one  of  his 
figures.  This  author  gives  a  most  exhaustive  bibliography  of  the 
subject. 

Care  must  be  exercised  in  the  diagnosis  of  these  tumours.  In  the 
case  related  the  spaces  filled  with  blood  after  the  removal  of  a  small 
portion  for  examination,  and  remained  so  filled  for  some  weeks.  Had 
it  been  examined  during  this  period  it  might  doubtless  have  been 
mistaken  for  a  haemangioma. 

I  have  also  seen  a  case  in  which  conjunctival  lymphangioma 
accompanied  lymphatic  dilatation  of  the  same  side  of  the  face.  The 
continuity  of  the  spaces  could  be  easily  demonstrated  by  pressing  the 
fluid  from  one  part  into  the  other. 


THE    CONJUNCTIVA 


127 


Sourdille  records  a  congenital  lymphangioma  of  the  conjunctiva, 
and  the  predisposing  condition  is  probably  generally  present  at  birth,  full 
development  being  gradual. 

Lymphangiomata  of  the  plica  semilunaris  have  been  reported  by 
Vossius  and  Sachs. 

STEUDEXER. — Virchow's  Archiv,  lix,  1874.  IMRE. — Wiener  med.  Woch.,  1876. 
LASKIEWICZ. — Nagel's  Jahresb.,  1877.  BULL. — Amer.  Jl.  of  Ophth.,  1878.  DELECCEUILLERIE. 
— These,  Paris,  1892.  ZIMMERMANX. — B.  z.  A.,  xxxvii,  1899.  UHTHOFF. — Berl.  klin. 
Woch.,  1879.  ALT. — Lectures  on  the  Human  Eye,  New  York,  1880.  JOCQS. — Soc.  fran9- 
d'Opht.,  1898.  SNELL.— Brit.  Med.  Jl.,  1898.  NETTLESHIP.— T.  O.  S.,  iv,  1884.  PARSONS. 
— In  MacCallan,  T.  O.  S.,  xxiii,  1903.  *  MEYERHOF. — K.  M.  f.  A.,  xl,  1902  (Bibliography). 
SOURDILLE. — A.  d'O.,  xviii,  1898.  Vossius. —  B.  d.  o.  G.,  1887.  SACHS. — Inaug.  Diss., 
Konigsberg,  1889  ;  Ziegler's  Beitrage,  v,  1889. 


CONGENITAL  TUMOURS 
Naevus.— The  conjunctiva  is  modified  skin,  and  like  the  skin,  it  is 


FlG.  64. PlGMENTED    N^EVUS    FROM    THE    PLICA    SEMILUNARIS.         X    60. 

The  growth  consists  chiefly  of  "  naevus  cells,"  which  are  seen  better  in  Fig.  65. 
Evidence  of  chronic  conjunctivitis  is  seen  in  the  slight  round-celled  infiltration, 
and  in  the  presence  of  new-formed  glands,  lined  by  epithelium  containing  many 
goblet-cells.  These  are  not  uncommon  in  nsevi  of  the  conjunctiva.  Amongst  the 
nsevus-cells  are  branched  pigmented  cells  (chromatophores). 

sometimes  the  seat  of  congenital  growths.  The  commonest  are  naevi, 
dermoids,  and  fibre-fatty  tumours. 

Nsevi  resemble  those  of  the  skin  ;  they  are  usually  pigmented,  rarely 
non-pigmented.  They  occur  merely  as  grey  or  brown  spots,  or  as 
reddish  or  brown  flat  swellings,  usually  at  the  limbus.  Both  types  are 
benign,  but  both  possess  high  potential  capacity  to  become  malignant. 

The  pignented  spots  are  flat,  and  are  made  up  of  groups  of  large 


128 


THE    PATHOLOGY    OF   THE    EYE 


cells  of  endothelial  type — round  or  polygonal,  flat,  often  with  processes. 
The  pigment  is  both  intra-  and  inter-cellular,  and  consists  of  golden 
or  brown  granules  or  heaps,  of  various  sizes.  The  connective-tissue 
cells  may  also  be  pigmented,  and  the  epithelium  over  the  spot  also 
frequently  contains  pigment.  When  these  spots  start  proliferating 
they  form  intensely  malignant  melanotic  growths. 

The  more  typical  nsevi  much  more  nearly  resemble  those  of  the 
skin  (Fig.  64).  They  are  slightly  swollen  and  gelatinous-looking,  and 
smooth.  The  epithelium  is  prolonged  downward  for  a  short  distance 
in  club-shaped  expansions,  which  divide  and  form  a  network.  In  the 
spaces  of  this  network  are  groups  of  smaller  epithelioid  cells — the 
so-called  "  nsevus  cells  "  (Fig.  65).  They  have,  therefore,  a  sort  of 
alveolar  arrangement,  and  are  separated  off  from  the  epithelial  cells 


FlG.  65. NON-PIGMENTED   NSEVUS  FROM  THE  LlMBUS.        X     I2O. 

From  the  limbus  at  the  outer  side.  The  "  nsevus-cells  "  are  well  seen.  They 
are  in  close  relationship  with  the  superficial  epithelium,  though  apparently  indepen- 
dent of  it.  Some  are  arranged  in  an  alveolar  manner,  others  are  diffuse.  There 
are  no  chromatophores. 

and  the  substantia  propria  by  strands  of  fibrous  tissue,  which,  however, 
forms  no  stroma  between  the  cells  except  at  the  periphery  of  the 
alveoli.  The  naevus-cells  are  usually  less  well  marked  off  on  the 
deeper  surface,  strands  of  white  and  elastic  fibres  passing  between 
them. 

The  nsevi  may  be  non-pigmented  or  pigmented.  In  the  latter  case 
the  pigment  is  present  throughout,  but  most  on  the  surface,  the 
epithelium  also  participating.  The  granules  are  brown  and  irregularly 
distributed ;  many  of  the  spindle-shaped  and  stellate  connective-tissue 
corpuscles  are  deeply  pigmented,  some  being  isolated,  others  forming 
bands.  These  have  been  called  chromatophores. 


THE    CONJUNCTIVA 


129 


Opinions  vary  as  to  the  ontogeny  of  the  naevus-cells.  Some  authors 
regard  them  as  epiblastic,  others  as  mesoblastic,  and  opinions  again 
vary  as  to  details.  Many  look  upon  them,  with  much  probability,  as 
endothelial  cells  (v.  Recklinghansen) ;  others  as  offspring  of  the  chroma- 
tophores  (Ribbert) ;  others  as  epithelial  cells  which  have  been  pinched 
off  from  the  normal  layers  (Unna),  and  these,  indeed,  regard  the 
chromatophores  themselves  as  descendants  of  epithelial  cells  (Abesser). 
When  they  become  malignant  they  are  named  according  to  the  views 
of  their  origin,  as  alveolar  sarcomata  or  endotheliomata,  or  as  epitheli- 
omata,  melanomata,  etc.  The  difficulty  is  exemplified  in  a  case 
reported  by  Lawford.  Leber,  from  a  study  of  malignant  forms,  thinks 
the  cells  are  epithelial.  It  is  suggestive  that  they  never  occur  isolated 


FIG.  66. — CYSTIC  X^EVirs  FROM  THE  LIMBUS.      x  60. 

From  a  specimen  by  Treacher  Collins.     The  growth  is  composed  of  a  mass  of 
"  nsevus-cells."  in  which  there  are  many  round  cystic  spaces. 

in  the  deeper  tissues,  but  always  in  connection  with   the  epithelial 
surface. 

It  is  common  to  find  cysts  in  these  tumours,  and  the  cystic  develop- 
ment may  be  very  pronounced  (Stoewer,  Pindikovvski)  (Fig.  66). 
This  has  been  cited  in  favour  of  the  endothelial  origin  of  the  cells,  the 
tumours  being  really  lymphomata.  In  Pindikowski's  case  the  cysts 
were  lined  with  a  double  layer  of  endothelium,  but  I  have  seen  them  as 
mere  holes,  the  lining  cells  differing  in  no  respect  from  the  surrounding 
nsevus-cells.  The  latter  are  pushed  apart,  and  may  be  much  reduced 
in  numbers;  their  alveolar  arrangement  may  be  lost,  and  in  some 
cases  is  absent  in  all  parts  (Best).  The  other  school  regard  these 
cysts  as  due  to  cystic  degeneration  of  the  gland-like  epithelial 
depressions,  and  the  presence  of  numerous  goblet-cells  lends  colour  to 

9 


130  THE    PATHOLOGY    OF   THE    EYE 

this  view  (Pindikowski).  The  cysts  are  most  frequently  empty  in 
sections — evidence  of  their  containing  simply  serous  fluid ;  or  they 
may  contain  coagula,  with  degenerated  cells,  or  even  hyaline  concre- 
tions (Wintersteiner). 

PARINAUD. — A.  d'O.,  iv,  1884.  RIBBEKT. — Ziegler's  Beitrage,  xxi,  1897.  UNXA. — 
Histopathologie  der  Hautkrankheiten,  1894.  WAELSCH. — Arch.  f.  Dermatologie  u.  Syph., 
xlix.  ABESSER. — Virchow's  Archiv,  clxvi,  1901.  LAWFORD. — T.  O.  S.,  xiii,  1893.  LEBER. 
— B.  d.  o.  G.,  1898.  WINTERSTEINER. — B.  d.  o.  G.,  1898.  BEST. — B.  z.  A.,  xxxvii,  1899. 
HIRSCH. — Z.  f.  A.,  iv,  1900.  STOEWER. — A.  f.  O.,  liv,  3,  1902.  PINDIKOWSKI. — A.  f.  A., 
xlii,  1901.  DE  SAVIGERIE. — La  Clin.  opht,  1900.  BALLABAN. — A.  f.  A.,  xliii,  1901. 

ROCKLIFFE. T.  O.   S.,  Xxi,   1901.       DE  SCHWEINITZ  AND  SWEET. Ophth.   Record,   1902. 

Epithelial  Plaques. — Bowman,  in  1853,  described  a  "  wart  "  which 
he  removed  from  the  cornea  of  a  woman  of  twenty-eight.  It  is  doubtful 
if  this  was  a  true  wart,  since  it  consisted  of  thickened  epithelium. 

Warlomont,  in  1860,  described  an  epithelial  opacity  of  the  lower 
and  outer  quadrant  of  the  cornea  ;  and  Hocquard,  in  1881,  reported 
cases  of  epithelial  proliferation.  They  are  of  two  kinds.  One  consists 


FIG.  67. — EPITHELIAL  PLAQUE,      x    10. 

From    Lister  and    Hancock  (R.  L.  O.  H.  Rep.,  xv).      From  a  man  aet.  24; 
noticed  at  least  ten  years. 

simply  of  local  hyperplasia  of  the  corneal  and  neighbouring  conjunc- 
tival  epithelium.  The  other  consists  of  a  white  mass  like  beaten-up 
white  of  egg.  It  is  easily  removed,  and  is  indeed  continually  being 
brushed  off  by  the  lids,  so  that  similar  masses  may  be  found  free  in  the 
lower  conjunctival  fornix.  The  epithelium  undergoes  fatty  degenera- 
tion. It  is  reproduced  in  from  three  to  thirty-six  hours.  These  are 
simply  cases  of  xerosis  conjunctivas  (Leber)  (q.  v.). 

Fumagalli  has  described  a  case  of  hyperplastic  epithelial  plaque, 
which  was  first  considered  to  be  a  pterygium.  It  extended  almost 
across  the  cornea,  and  vision  was  reduced  to  perception  of  light.  It 
was  easily  removed,  and  sight  was  completely  restored  and  retained. 
The  growth  consisted  simply  of  very  thick  stratified  epithelium,  the 
cells  of  which  were  actively  proliferating,  as  shown  by  karyokinetic 
figures. 

Probably  none  of  these  cases  are  worthy  of  a  separate  designation. 
They  are  all  either  cases  of  xerosis  of  the  conjunctiva  or  of  epidermoid 
changes  in  the  cornea,  which  occur  under  all  conditions  of  exposure, 
e.  g.  lagophthalmia,  etc.  There  is,  however,  a  very  small  group  of 


THE    CONJUNCTIVA 


FIG.  68. — EPITHELIAL  PLAQUE,      x  80. 

From    Lister   and  Hancock.     Showing  the  superficial  horny  layers,  stratum 
granulosum,  and  infiltration  of  the  adenoid  layer. 


FIG.  69. — EPITHELIAL  PLAQUE,      x  80. 

From    Lister  and   Hancock.       Showing   the    sharply    defined    margin    of   the 
growth.     From  a  girl  act.  15. 


132 


THE    PATHOLOGY    OF   THE    EYE 


cases  to  which  the  distinctive  term  "  epithelial  plaque  "  may  be  con- 
veniently applied. 

I  have  had  the  opportunity  of  examining  two  such  cases.  In  each 
case  they  occurred  in  young  patients  and  were  probably  congenital.  In 
one  the  plaque  occupied  the  typical  position  of  a  dermoid  tumour, 
being  partly  over  the  cornea,  out  and  up.  In  the  other  it  was  in  a 
similar  direction,  but  separated  from  the  cornea  by  normal  conjunctiva. 
In  each  case  the  epithelium  was  much  thickened  and  the  superficial 
layers  were  corneous.  I  think  these  plaques  are  the  simplest  expression 


FIG.  70. — EPITHELIAL  PLAQUE,      x   15. 

From  Lister  and  Hancock.     Showing  the  great  hypertrophy  of  the  epithelium. 
From  a  man  aet.  51,  following  an  injury. 

of  a  dermoid  tumour,  only  the  epidermal  elements  being  represented, 
those  of  the  cutis  vera  being  absent. 

Hancock  and  Lister  have  recently  collected  cases  of  this  type. 

BOWMAN. — Ann.  d'Oc.,  xxx,  1853.  WARLOMONT. — Ann.  d'Oc.,  xliv,  1860.  HOCQUARD. 
— A.  d'O.,  i,  1881.  FUMAGALLI. — Arch,  per  le  Sc.  med.,  xvi.  LEBER. — A.  f.  O.,  xxix,  3, 
1883.  BEST. — K.  M.  f.  A.,  xxxviii,  1900.  *HANCOCK  AND  LISTER. — R.  L.  O.  H.  Rep., 
xv,  4,  1903. 

Dermoid. — Dermoids  are  lenticular  yellow  or  reddish  congenital 
tumours  which  occur  astride  the  corneal  margin,  usually  on  the  outer 
side,  and  contain  the  elements  of  skin  (stratified  epithelium,  hairs, 
sebaceous  glands,  etc.)  (Fig.  71).  They  were  described  as  early  as 
1742,  and  four  cases  were  published  by  Wardrop  (1808) ;  they  were 
named  "dermoids"  by  Ryba  (1853). 

While  commonest  at  the  outer  part,  they  occur  rarely  at  any  part 
of  the  limbus,  and  even  under  the  outer  canthus,  etc.  Examples  are 
given  by  Vassaux.  They  are  often  associated  with  other  congenital 
malformations  (twenty-seven  out  of  ninety-four  [Picque]),  "  colobo- 
mata"  of  the  lids,  fleshy  bands  from  the  globe  to  the  face,  etc.  They 
occur  in  lower  animals  (cf.  Oeller),  and  have  wool  instead  of  hairs  in  the 
sheep  (Museum,  R.  C.  S.)  (Bland-Sutton).  They  rarely  start  growing 
until  puberty,  and  it  is  then  that  the  hairs  develop.  They  may  be  as 
small  as  a  pin's  head,  or  so  large  as  to  project  between  the  lids.  The 
base  is  generally  oval,  with  the  long  axis  horizontal,  and  they  are 


THE    CONJUNCTIVA 


133 


nearly  flat,  but  may  be  rarely  pedunculated  (Snell)  (Fig.  73).  When 
there  is  a  notch  in  the  lid  the  tumour  corresponds  in  position  with  the 
gap.  They  usually  have  few  or  no  vessels,  and  are  hard — rarely  soft. 
They  are  sometimes  covered  with  sebaceous  secretion  (Vassaux,  van 
Duyse). 

The  epithelium  has  all  the  characteristics  of  true  epidermis, 
possessing  a  superficial  horny  layer,  stratum  lucidum,  stratum  granu- 
losum,  and  Malpighian  layer  of  prickle-cells. 

The  corium  consists  of  fibrous  tissue,  with  many  elastic  fibres,  and 
a  few  vessels.  The  papillae  are  usually  ill-developed.  Pigmented  spots 
have  been  found  in  the  superficial  layers  (Vassaux).  The  deeper  layers 
are  areolar,  the  fibres  being  more  loosely  set,  and  containing  fat,  which 


FIG.  71. — DERMOID  OF  THE  CONJUNCTIVA. 

Argyll-Robertson  (T.  O.  S.,  xiv).       Note  the  hairs  upon  the  surface, 
position  is  as  usual,  up  and  out,  but  is  unusually  far  from  the  cornea. 


The 


may  be  conspicuously  developed  and  form  a  connecting  link  with  the 
fibro-fatty  tumours.  In  the  deepest  part  the  fibres  are  continuous 
with  those  of  the  sclerotic,  so  that  the  tumour  is  immovable  upon  the 
eye ;  rarely  it  is  movable.  Nearly  all  dermoids  contain  hairs  with 
well-developed  follicles  and  sebaceous  glands.  Sweat-glands  are  rare, 
but  have  been  found  (Heyfelder,  Vassaux,  Gallenga)  (Fig.  73)  ;  some 
are  more  nearly  allied  to  Moll's  modified  sweat-glands.  Medullated 
nerves  have  been  found  in  the  deep  layers  (Vassaux),  and  in  a  fleshy 
band  (Poncet)  which  has  exactly  the  same  structure  (Manz,  Nuel, 
Lannelongue,  van  Duyse,  Poncet).  Dermoids  rarely  contain  cartilage 
(Gallenga). 

Various   theories   have    been    suggested    for   the    explanation    of 
dermoids.      Ryba  suggested  failure  of  complete  closure  of  the  lids, 


134 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  72. — DERMOID  OF  THE  LIMBUS.      x  55. 

From  a  boy  xt.  3  ;  it  was  situated  astride  the  limbus,  down  and  out.  It 
consists  chiefly  of  hyaline  connective  tissue  with  a  few  small  blood-vessels  covered 
by  epidermis,  which  is  horny  on  the  surface  in  places.  The  section  shows  a  hair- 
follicle  and  sebaceous  gland. 


FIG.  73. — DERMOID  OF  THE  CONJUNCTIVA,      x  20. 

From  the  case  reported  by  Snell  and  Treacher  Collins  (T.  O.  S.,  xx). 
Pedunculated  dermoid  from  upper  and  outer  part  of  conjunctiva  of  a  boy  set.  5 
months.  Note  the  enormous  number  of  sweat-glands.  There  were  a  few  hair- 
follicles  in  the  terminal  part,  and  several  sebaceous  glands  in  the  pedicle. 


THE   CONJUNCTIVA  135 

with  consequent  cornification  of  the  conjunctiva,  and  cited  the  corre- 
spondence of  dermoid  and  lid-notch.  This  view  is  supported  by  Bland- 
Sutton  and  Treacher  Collins ;  the  latter  regards  cryptophthalmia,  in 
which  the  whole  surface  of  the  eyeball  is  covered  with  skin,  as  the 
ultimate  manifestation  of  dermoid  development.  Gallenga  drew  atten- 
tion to  the  plica  semilunaris.  which  in  foetal  life  covers  the  globe,  like 
its  phylogenetic  equivalent  the  nictitating  membrane.  He  thought  it 
might  remain  adherent  to  the  limbus.  Osborn  thought  the  tumour 
might  be  a  remnant  of  the  epiblast  which  forms  the  lens,  van  Duyse 
considered  it  was  due  to  adhesion  of  the  amnion  to  the  eye.  This 
theory  has  been  held  in  modified  form  by  Lannelongue  and  Vassaux. 

The  eye  is  usually  otherwise  normal,  but  there  is  a  group  of  cases 
in  which  it  is  congenitally  deformed.  Such  cases  are  described  by 
Schmidt-Rimpler,  Swanzy,  Bernheimer,  Manfredi,  Wagenmann,  etc. 
In  Wagenmann's  case  there  was  bone  in  the  dermoid  or  teratoid 
tumour. 

Sweat-glands  were  present  in  Swanzy's  case,  and  besides  those 
mentioned  there  is  a  group  in  which  similar  serous  acinotubular  glands 
are  present,  with  much  fatty  tissue,  striped  and  unstriped  muscle- 
fibres,  hyaline  bodies,  bone,  and  nerves.  They  are  covered  by  con- 
junctival  epithelium  with  goblet-cells,  and  form  a  further  link  towards 
the  fibro-fatty  and  more  purely  orbital  teratoid  growths.  They  are 
supposed  to  represent  the  fornix  area,  the  glands  being  Krause's  glands 
(Falchi).  When  these  growths  are  combined  with  dermal  tissues, 
Gallenga  supposes  that  the  dermoid  leads  to  the  malposition  of 
Krause's  glands  by  being  intruded  into  the  normal  tissues  ;  but  it 
must  be  remembered  that  Krause's  glands  are  inconstant  in  position. 

The  epithelium  even  in  ordinary  dermoids  is  not  always  epidermal, 
but  may  be  conjunctival,  especially  when  the  growth  is  covered  by  the 
lids.  If  it  projects  between  the  lids  the  exposed  part  becomes  horny, 
but  this  is  the  case  in  many  other  pathological  conditions,  e.g.  anterior 
staphyloma,  etc. 

WARDROP. — Essays  on  the  Morbid  Anatomy  of  the  Eye,  Edinburgh,  1808.  RYBA. — 
Prager  Vierteljahresschrift,  iii,  1853.  VASSAUX. — A.  d'O.,  iii,  1883.  PICQUE. — These,  Paris, 
1886.  OELLER. — A.  f.  A.,  x,  1881.  BLAND-SUTTON. — Tumours,  London.  TREACHER 
COLLINS. — Lancet,  1900.  SNELL. — T.  O.  S.,  xx,  1900.  VAN  DUYSE. — Ann.  de  la  Soc.  med. 
de  Gand,  1882.  VAN  DUYSE  AND  BRIBOSIA. — A.  d'O.,  xv,  1895.  GALLENGA. — Ann.  d'Oc., 
xciv,  1885;  Ann.  di  Ott,  xxviii,  1899.  HEYFELDER. — In  Fuchs,  K.  M.  f.  A.,  xviii,  1880. 
POXCET. — Bull,  de  la  Soc.  de  Chir.,  iv,  1883.  MANZ. — A.  f.  O.,  xiv,  2,  1868.  LANNELONGUE 
AND  ACHARD. — Traite  des  Kystes  congenitaux,  Paris,  1886.  OSBORN. — St.  Thomas's  Hosp. 
Rep.,  vi,  1875.  SCHMIDT-RIMPLER. — A.  f.  O.,  xxiii,  4,  1877.  SWANZY. — Dublin  Quarterly 
Jl.  of  Med.  Sc.,  1871.  BERNHEIMER. — A.  f.  A.,  xviii,  1888.  MANFREDI. — Riv.  Clin.,  v, 
1869.  WAGENMANN. — A.  f.  O.,  xxxv,  3,  1889.  FALCHI. — A.  f.  A.,  xl,  1900. 

Dermo-lipoma. — Fibro-fatty  tumours  of  congenital  origin  are  found 
usually  in  the  same  situation  as  dermoids,  at  the  outer  margin  of  the 
cornea,  or  farther  out,  between  the  insertions  of  the  superior  and 
external  recti.  The  conjunctiva  is  generally  thickened.  They  are 
usually  yellow,  about  the  size  of  a  pea  or  bean. 

Microscopically  they  consist  of  fatty  tissue  with  irregular  strands  of 
fibrous  tissue  (Fig.  74).  They  were  at  first  described  as  ordinary 
lipomata,  the  earliest  being  recorded  by  Kranke  (1854).  Some,  e.  g. 


136 


THE    PATHOLOGY   OF   THE    EYE 


Querenghi's,  may  indeed  be  simple  lipomata.  Reuss,  in  1891,  could 
only  collect  twenty  cases.  After  that  they  increased  in  interest,  owing 
to  the  discovery  of  other  tissues.  Talko  found  glandular  tissue  and 
hyaline  cartilage  (lipo-chondro-adenoma  bulbi).  Other  observers  found 
elements  of  skin,  as  in  the  ordinary  dermoids.  Rieke  insisted  upon  the 
necessity  of  extremely  careful  examination,  as  the  cutaneous  elements 
may  be  limited  to  a  single  stunted  hair-follicle  or  sebaceous  gland,  so 
that  it  is  sometimes  necessary  to  make  serial  sections.  A  very  careful 
investigation  of  four  cases  from  this  point  of  view  was  carried  out  by 
Nobbe,  under  the  supervision  of  Leber.  In  all  cases  hairs  and 
sebaceous  glands  were  found,  and  in  one  an  accessory  lacrymal  gland, 
in  another  smooth  and  striped  muscle-fibres.  Rogman,  on  the  other 
hand,  failed  to  find  dermal  elements  in  one  of  five  tumours  examined, 


FIG.  74. — DERMO-LIPOMA.      x   7. 

From  a  child  set.  I  year.     The  tumour  consists  of  fibrous  and  adipose  tissue, 
covered  by  conjunctiva.     Near  the  edge  below  acini  of  lacrymal  gland  are  seen. 

so  that  their  teratoid  nature  cannot  in  all  cases  be  demonstrated.  This 
is  confirmed  by  one  of  Lagrange's  three  cases.  Fibro-fatty  tumours 
have  also  been  recorded  by  Derby,  Bogel,  Wiirdemann,  Alt,  Weyman, 
Marcus  Gunn,  etc.  Other  transition  forms  from  true  dermoids  have 
been  already  alluded  to  (v.  p.  133).  The  true  dermoid  described  by 
Hirschberg  and  Birnbacher,  occurring  in  the  equatorial  region,  is 
interesting  as  showing  that  these  growths  are  not  limited  to  the  limbus 
and  the  caruncle. 

The  tumours  are  always  congenital,  but  are  often  not  noticed  at 
once  owing  to  their  position  up  and  out,  under  the  upper  lid,  and  also 
owing  to  the  fact  that,  like  dermoids,  they  may  start  growing  at 
puberty;  but  this  is  less  common  with  the  lipo-dermoids.  They  have 


THE    CONJUNCTIVA 


137 


been  described  mostly  in  girls.  They  are  essentially  conjunctival,  and 
not  orbital  growths,  as  held  by  von  Graefe.  The  same  theories  are  said 
to  account  for  them  as  for  dermoids,  but  the  occurrence  of  simple 
lipomata  cannot  be  eliminated.  Lagrange  considers  that  the  con- 
junctiva moves  freely  over  lipomata,  but  is  adherent  to  dermo-lipomata. 

KRANKE. — Ann.  d'Oc.,  xxxi,  1854.  DERBY. — T.  Amer.  O.  S.,  1878.  BOGEL. — A.  f.  O., 
xxxii,  i,  1886.  TALKO. — K.  M.  f.  A.,  xxvi,  1888.  RIEKE. — A.  f.  A.,  xxii,  1890.  REUSS. — 
C.  f.  A.,  xv,  1891.  *NOBBE. — A.  f.  O.,  xliv,  1897.  ROGMAN. — Ann.  d'Oc.,  cxix,  1898. 
*LAGRANGE. — Tumeurs  de  1'CEil,  i,  Paris,  1901.  WURDEMANN. — Amer.  JI.  of  Ophth.,  1888. 
ALT. — Amer.  Jl.  of  Ophth.,  1889.  WEYMAN. — Ophth.  Rec.,  1892.  MARCUS  GUNN. — Ophth. 

Rev.,   1889.       HlRSCHBERG  AND  BlRNBACHER. C.  f.  A.,  vii,   1883. 

Osteoma. — Osteomata  of  the  conjunctiva  have  been  observed  by 
v.  Graefe  (1863),  Saemisch,  de  Wecker,  Anderson  Critchett,  Spencer 


FIG.  75. — OSTEOMA  OF  THE  CONJUNCTIVA,      x  55. 

From  a  girl  set.  14 ;  lying  upon  the  sclerotic  external  to  the  cornea  ;  adherent 
to  globe,  but  not  to  conjunctiva.     It  consists  of  true  bone  ;  there  is  no  cartilage. 

Watson,  Shadford  Walker,  Loring,  Snell,  Vignes,  Galtier,  Cirincione, 
Hartridge,  and  Heustis.  I  have  myself  examined  three  such  tumours  from 
different  patients.  They  are  therefore  not  so  rare  as  might  be  thought. 

They  always  occur  in  the  upper  and  outer  quadrant,  between  the 
tendons  of  the  superior  and  external  recti ;  they  are  always  congenital. 
They  may  be  definitely  classified  amongst  the  teratomata,  and  are 
probably  examples  of  atavism,  a  reversion  to  the  types  in  which  plaques 
of  bone  are  found  in  the  skin.  They  have  nothing  to  do  with  the  plaques 
of  bone  found  in  the  sclerotic  of  birds,  etc.,  since  they  are  always  in 
the  conjunctival  stroma,  and  are  movable  over  the  normal  sclerotic. 
They  have  been  explained  on  the  same  theory  as  dermoids  (q.  v.). 

The  tumour  is  usually  convex  on  the  upper  and  flattened  on  the  deep 
surface.  It  is  surrounded  by  periosteum,  which  is  embedded  in  the 


138  THE    PATHOLOGY    OF  THE    EYE 

substantia  propria  of  the  conjunctiva.  The  bone  is  usually  irregularly 
developed,  the  laminae  running  in  all  directions  (Fig.  75).  They  are 
roughly  arranged  in  Haversian  systems  around  the  thin-walled  vessels, 
and  have  numerous  typical  bone-corpuscles.  None  of  mine  contained 
cartilage,  but  they  often  do. 

v.  GRAEFE. — K.  M.  f.  A.,  i,  1863.  SAEMISCH. — In  de  Wecker,  Traite  d'Opht,  i, 
p.  426,  1880.  DE  WECKER. — Traite  d'Opht.,  i,  p.  427,  1880.  ANDERSON  CRITCHETT. — 
T.  O.  S.,  ii,  1882.  SPENCER  WATSON. — Brit.  Med.  Jl.,  1882.  SHADFORD  WALKER. — Brit. 
Med.  Jl.,  1882.  LORING.— New  York  Med.  Jl.,  1883.  SNELL.— T.  O.  S.,  iv,  1884.  VIGNES. 
— Soc.  fran9_  d'Opht.,  1889.  GALTIER. — Ann.  d'Oc.,  cxiii,  1895.  CIRINCIONE. — Lav.  d. 
Clin.  Oc.  di  Napoli,  iv,  1895.  HARTRIDGE. — T.  O.  S.,  xv,  1895.  HEUSTIS. — Ann.  of  Ophth., 
viii,  1899.  CONTINO. — Clin.  Oculistica,  1900. 

ADENOMA 

Adenoma  of  the  conjunctiva  can  only  occur  where  there  are  true 
glands.  They  are  found  in  the  caruncle  (q.  v.)  ;  others  have  been 
described  growing  from  Krause's  glands  (Moauro,  Rumschewitsch,  Salz- 
mann)  (v.  p.  27).  One  occurred  in  a  man  of  thirty-four,  and  consisted 
of  gland-lobules  of  ordinary  type,  with  interlobular  tissue  consisting  of 
typical  granulation  tissue  (adeno-granulonia).  The  upper  part  was 
chiefly  glandular,  the  lower  granulation  tissue.  Another  occurred  in  a 
girl  of  nine;  the  growth  was  3  cm.  long  by  1*5  cm.  broad  by  i  cm. 
thick,  and  was  in  the  outer  part  of  the  upper  fornix.  It  consisted  of 
gland-lobules  with  dilated  spaces  (cysts)  in  the  upper  and  lower  parts. 
There  was  a  considerable  amount  of  fibrous  tissue  between  the  lobules 
(fibre-adenoma  cystoideum)  (Rumschewitsch). 

MOAURO. — Riv.  internaz.  di  Med.  e  Chir.,  iv,  Napoli,  1887.  RUMSCHEWITSCH. — 
K.  M.  f.  A.,  xxviii,  1890;  xl,  1902.  SALZMANN. — A.  f.  A.,  xxii,  1891.  SCHIRMER. — A.f.  O., 
xxxviii,  i,  1891. 

SARCOMA 

Sarcoma  of  the  conjunctiva  occurs  most  commonly  at  the  limbus 
as  an  epibulbar  growth  (Fig.  76).  The  first  case  in  which  it  can  be 
isolated  from  the  general  description  of  "  cancer  " 
of  the  conjunctiva  was  reported  by  Baumgarten 
in  1852.  Since  then  over  eighty  cases  have  been 
recorded,  but  this  gives  little  idea  of  its  relative 
frequency. 

Epibulbar  sarcomata  arise  in  the  conjunctiva 
at  or  very  near  the  limbus,  especially  in  the  more 

exposed   parts,   i.  e.   in   the   palpebral   aperture 

FIG.  76.-SARcoMA  OF  THE   (Paiias).     Several  cases  have  occurred  in  which 
LIMBUS.  they  were  multiple  at  the  limbus,  and  after  re- 

After  Lawson.  moval  they  may   recur   at  some  other  spot  in 

this  situation.     They  are  usually  pigmented,  but 

non-pigmented  sarcomata  also  occur  (12  to  61),  and  recurrent  tumours 
are  sometimes  non-pigmented  when  the  primary  growth  was  pigmented, 
and  vice  versa  (Weinbaum).  Metastatic  deposits  from  melanotic  sarco- 
mata may  be  non-pigmented,  as  in  the  case  of  the  choroid,  etc. 
Pigmented  connective-tissue  cells  are  sometimes  found  at  the  corneal 


THE   CONJUNCTIVA  139 

margin,  and  may  form  aggregates  (melanomata  [Virchow])  ;  these  are 
always  present  in  dark  races.  They  often  form  the  starting-point  of 
malignant  growths.  Such  growths  are  sarcomata,  and  must  be  dis- 
tinguished from  malignant  growths  originating  in  congenital  nsevi, 
which  must  now  probably  be  regarded  as  carcinomata  (v.  p.  127). 
Confusion  arises  from  the  application  of  the  term  melanoma  to  both 
types  when  they  are  pigmented. 

The  tumours  may  appear  as  black,  brown,  or  red  smooth  round 
elevations  or  nodular  masses,  often  friable  and  bleeding  readily.  They 
are  at  first  movable  with  the  conjunctiva  over  the  sclerotic.  The  base 
is  nearly  always  small,  even  when  the  growths  are  large,  so  that  they 
often  lie  over  the  cornea  without  being  adherent  to  it — a  point  of  dis- 
tinction from  epithelioma.  In  one  case  the  pedicle  was  1*5  cm.  long 
(Bloch) ;  but  the  tumour  may  be  a  diffuse  flat  swelling.  The  corneal 
stroma  is  not  usually  invaded,  or  at  most  in  the  superficial  layers  only. 
In  Wads  worth  and  VerhoefFs  case  the  anterior  third  was  infiltrated, 
and  the  whole  cornea  may  be  involved  in  late  stages  (Sgrosso).  In- 
crease in  growth  takes  place  principally  in  the  conjunctiva,  so  that  the 
tumour  can  still  be  moved  over  the  globe.  The  largest  was  the  size  of 
an  orange,  and  was  entirely  extra-bulbar  (Adamtick).  Accounts  show 
that  they  take  about  a  year  to  become  the  size  of  a  pea  or  bean. 
Sgrosso,  Green  and  Ewing,  and  Lagrange  report  cases  where  the 
patient  had  noticed  a  small  spot  thirty,  twenty-five,  and  fifteen  years 
respectively,  which  finally  underwent  sudden  growth  and  extension. 
A  small  tumour  may  rarely  be  accompanied  by  wide-spread  pigmenta- 
tion of  the  conjunctiva  (Greeff). 

The  patients  are  usually  old,  but  Krautner,  Benson,  and  Schultze 
report  cases  at  eight,  eleven,  and  fourteen  years  respectively.  The 
average  is  fifty-one.  There  is  a  history  of  injury  in  six  cases,  and 
occasionally  pterygium  (Strouse). 

The  general  opinion  as  to  malignancy  is  voiced  by  Strouse,  who 
says  that  epibulbar  sarcomata  never  penetrate  the  globe,  and  rarely 
produce  metastases.  Verhoeff  and  Loring  regard  them  as  highly 
malignant,  judging  by  their  tendency  to  recur  ,and  form  metastases. 
They  give  the  following  results  : 

Total  primary  abscissions        .         .  '.         .         .'        .         ,         .     53 
No  recurrence : 

After  6  months'  observation  .         .         . ,        .         i 
„     i  year's              „  4 

,,       2         ,,  ,,  .... 

,,     several  (4  and  10)  years'  observation    .       ' .         2 

o 

Recurrence  : 

Within  i  year .10 

2  years '   ••       3 

„       several  years  (4,  6,  10,  6)  .         .         .         .         4 

Time  not  stated    .  19 

36 
Not  followed  after  operation         ....  9 

53 


140  THE    PATHOLOGY   OF   THE    EYE 

Of  the  thirty-six  cases  with  recurrence,  metastasis  occurred  in  eight, 
and  recurrence  in  lids  and  orbit  in  four  others.  These  results  and 
further  analysis  of  the  cases  would  seem  to  show  that  the  general 
opinion  is  wrong,  and  that  the  growths  are  extremely  malignant,  and 
should  be  treated  by  radical  methods  (primary  enucleation). 

Microscopically  sarcomata  of  the  limbus  show  few  peculiarities. 
They  are  usually  round-  or  spindle-celled,  the  cells  being  of  various  sizes 
in  different  cases,  and  generally  arranged  in  bundles. 

Multinuclear  cells  may  also  occur  in  them  (Wadsworth  and 
Verhoeff).  These  are  not  true  giant-cells,  like  those  found  in  myeloid 
sarcoma,  but  are  probably  merely  evidence  of  the  rapid  cell-division 
which  is  going  on,  nuclear  division  proceeding  more  rapidly  than  that 
of  the  cells. 

Still  more  commonly,  however,  they  have  an  alveolar  arrangement, 
rings  and  columns  of  cells  being  enclosed  in  fibrous-tissue  framework. 
These  alveolar  sarcomata  probably  arise  in  pigmented  or  non-pigmented 
naevi.  This  peculiarity  in  structure  has  led  Panas  to  doubt  the 
frequency  of  sarcomata  at  the  limbus.  He  thinks  that  they  are 
commonly  multiple,  and  arise  at  some  distance  from  the  limbus 
(peribulbar).  The  strictly  epibulbar  (limbus)  tumours  he  regards  as 
mixed  epithelioma  and  sarcoma,  and  as  non-malignant.  This  revolu- 
tionary idea  cannot  be  held.  These  growths  belong  to  a  well-known 
type  described  by  Virchow  as  sarcoma  carcinomatoides,  and  most  often 
called  alveolar  sarcoma  in  England. 

Their  nomenclature  depends  upon  the  nature  of  the  nsevus-cells 
from  which  they  arise,  and  this,  as  we  have  seen  (v.  p.  129),  is  a  matter  of 
dispute.  If  we  regard  the  mother  cells  as  endothelial,  these  growths 
are  endotheliomata.  In  any  case  endotheliomata  probably  occur  in 
the  limbus,  derived  from  the  endothelium  of  the  blood-vessels  or 
lymphatics  (see  "  Cornea  ").  If  naevus-cells  are  regarded  as  epithelial, 
in  accordance  with  an  increasing  consensus  of  opinion,  the  growths  are 
epitheliomata  or  carcinomata.  The  question  of  nomenclature  is 
perhaps  of  little  importance,  but  the  mixture  of  ideas  involved  in 
asserting  the  simultaneous  occurrence  of  carcinoma  and  sarcoma 
(Panas)  is  to  be  avoided. 

Cases  of  this  type  have  been  described  by  Schultze  (two),  de  Laper- 
sonne  and  Curtis  (one),  and  Panas  (five),  but  they  really  form  an  un- 
usually large  proportion  of  sarcomata  in  this  region.  The  epithelioid  cells 
are  said  by  some  not  to  be  connected  with  the  superficial  epithelium, 
though  they  often  appear  to  be  so.  The  epithelium  passes  unchanged 
or  thinned  over  the  surface  ;  but  it  is  not  unusual  to  see  "  alveoli  "  of  the 
cells  embedded  in  and  encroaching  upon  the  epithelium,  a  condition 
very  reminiscent  of  congenital  moles.  There  are  often  polynuclear 
leucocytes  between  the  sarcoma  cells. 

The  pigment  in  these  tumours  may  be  purely  intra-cellular,  or  may 
be  also  between  the  cells.  Masses  of  granules  may  also  be  found  in  the 
vessels,  or  in  obliterated  vessels,  or  within  fusiform  cells  near  the 
vessels  (Birnbacher).  Different  views  are  held  as  to  its  origin  in 
these  and  other  melanotic  sarcomata — whether  developed  by  the 
tissue  cells  (autochthonous)  or  from  haemoglobin  (haematogenous). 


THE    CONJUNCTIVA  141 

The  question  will  be  discussed  more  fully  in  dealing  with  sarcoma  of 
the  choroid. 

Whilst  penetration  of  the  globe  in  these  cases  is  extremely  rare,  it 
sometimes  occurs  (Kerschbaumer) ;  the  growth  then  passes  along  the 
perforating  anterior  ciliary  vessels.  In  one  case  sarcomatous  cells 
were  found  in  the  canal  of  Schlemm.  The  intra-ocular  invasion  is  never 
extensive.  Invasion  of  the  cornea  is  always  at  first  between  Bowman's 
membrane  and  the  epithelium. 

Sarcoma  in  other  parts  of  the  conjunctiva  is  very  rare.  One  case 
has  been  published  in  which  it  occurred  in  the  upper  fornix  (Griffith). 
In  another  it  arose  at  the  inner  angle  in  the  socket  of  an  enucleated 
eye  (Gorecki). 

Cases  of  sarcoma  of  the  palpebral  conjunctiva  have  been  published 
by  Mittendorf,  Ewetzki,  and  Feilchenfeld.  They  are  sometimes  pedun- 
culated.  The  first  was  in  a  woman  set.  46 ;  there  were  repeated 
small  recurrent  tumours :  the  pre-auricular  and  cervical  glands  were 
swollen.  The  second  was  a  melanotic  sarcoma  in  the  conjunctiva  of 
the  lower  lid  of  a  man  set.  53 ;  it  consisted  of  round  and  oval  cells ; 
there  were  two  isolated  pigmented  naevi  on  the  border  of  the  lid.  The 
third  case  was  a  round-celled,  non-pigmented  growth  between  the 
tarsus  and  the  conjunctiva,  and  invading  the  tarsus,  Meibomian  glands, 
and  Riolan's  muscle. 

Melanotic  sarcomata  of  the  plica  semilunaris  have  been  published 
by  Pfliiger  (in  a  man  set.  39 — recurred),  Rumschewitsch  (in  a  man 
set.  22 — alveolar — recurred  and  caused  death),  Meighan,  and  de 
Berardinis.  Lympho-sarcomata  have  been  reported  by  Piccoli  and 
Vollaro.  They  had  the  structure  of  adenoid  tissue,  and  there  were 
giant-cells  in  the  second  case. 

*LAGRANGE. — Tumeurs  de  1'CEil,  i,  Paris,  1901  (Bibliography).  *V~ERHOEFF  AND  LORING. 
— A.  of  O.,  xxxii,  1903  (Bibliography).  BAUMGARTEN. — Arch.  f.  Heilk.,  xvi,  1852.  PANAS. 
— A.  d'O.,  xxii,  1902.  WEINBAUM. — A.  f.  O.,  xxxvii,  i,  1891.  WADSWORTH  AND  VERHOEFF. 
— T.  Am.  O.  S.,  1901.  SGROSSO. — Ann.  di  Ott.,  xxi,  i,  1892.  ADAMUCK. — A.  f.  A.,  xi, 
1881.  GREEFF. — In  Orth,  Lehrbuch,  Berlin,  1902.  KRAUTNER. — K.  M.  f.  A.,  xxxviii,  1900. 
BENSON. — Ophth.  Rev.,  vi,  1887.  SCHULTZE. — K.  M.  f.  A.,  xxxii,  1894.  STROUSE. — A.  of 
O.,  xxvi,  i,  1897.  DE  LAPERSONNE  AND  CURTIS. — A.  d'O.,  xvii,  1897.  BIRNBACHER. 
— C.  f.  A.,  viii,  1884.  LAWFORD.— R.  L.  O.  H.  Rep.,  xii,  3,  1889;  T.  O.  S.,  xvi,  1897; 
xxi,  1901.  KEKSCHBAUMER. — Das  Sarkom  des  Auges,  Wiesbaden,  1900.  GRIFFITH. — 
T.  O.  S.,  xx,  1900.  GORECKI. — Soc.  fran9.  d'Opht.,  1892.  MITTENDORF. — Amer.  JI.  of 
Ophth.,  1886.  EWETZKI.— Nagel's  Jahresb.,  1886.  FEILCHENFELD.— C.  f.  A.,  xii,  1888. 
PFLUGER. — Univ.  Augenheilklinik  Bericht,  1883.  RUMSCHEWITSCH. — K.  M.  f.  A.,  xxix, 
1891.  MEIGHAN. — Glasgow  Med.  Jl.,  xxxviii.  DE  BERARDINIS. — Ann.  di  Ott.,  xxxi,  1902. 
PICCOLI. — Lav.  della  Clin.  Oc.  di  Napoli,  iv,  1895.  VOLLARO. — Ann.  di  Ott.,  xxviii,  1899. 


EPITHELIOMA 

Epithelioma  occurs  par  excellence  where  one  kind  of  epithelium 
passes  into  another,  as  at  the  anus,  lips,  edge  of  lids,  etc.  So,  too,  in  the 
conjunctiva  it  occurs  at  the  edge  of  the  lids  (p.  21)  and  at  the  limbus 
(Fig.  77).  Here  it  is  commonly  at  the  outer  side  (Panas),  but  it  also 
occurs  in  other  parts,  and  when  it  starts  at  a  distance  from  the  edge  of 
the  cornea  it  is  often  on  the  nasal  side  (Lagrange).  It  is  usually 


142 


THE    PATHOLOGY    OF   THE    EYE 


papillary  or  wart-like  at  first,  about  the  size  of  a  small  pea,  but  it  may 
grow  to  an  enormous  size  and  project  as  a  fungating  mass  between 
the   lids.     It    may    much    resemble    a   dermoid 
at   first,  but   later  it  spreads  out,  covering  the 
cornea  and  sclerotic,  though  its  attachment  to 
the  globe  may  be  small.     It  may  simply  cover 
the  cornea,  only  involving  the  epithelium,  but 
this  is  rarer  than  with  the  epibulbar  sarcomata. 
It  generally  infiltrates  the  substantia  propria  of 
the  cornea  widely.     It  is  almost  invariably  single, 
but  Manz  records  a  case  with  four  nodules.     The 
surface  in  late  stages  ulcerates,  and  small  haemor- 
FIG.  77.— EPITHELIOMA  OF  rnages  take  place,  the  blood-pigment  becoming 
t,      almost  black,  but  true  pigmentation  may  also  be 

After  Lawson.     From  the  •* 

Museum  of  the  R.  L.  o.  H.  present.     A    sero-purulent    exudate    may   occur 
from   irritation.     Lagrange  regards  implication 

of  the  lymphatic  glands  as  rare,  but  it  certainly  occurs,  the  pre-auricular 
first  and  the  submaxillary  glands  later  being  affected.  The  growth 
extends  widely  over  the  sclerotic  (Figs.  78,  79),  and  in  rare  cases  sur- 
rounds the  cornea  (peribulbar  epithelioma  [Heyder]). 

Recurrence  after  local  removal  is  common.  Trousseau  records  six 
cases  where  this  treatment  was  successful,  but  I  think  that  cases  of 
simple  epithelial  hyperplasia  occur  in  which  masses  of  epithelium 
are  formed,  much  resembling  those  found  in  epithelioma.  In  the 
small  piece  which  is  excised  for  pathological  examination  the  knife 
often  fails  to  pass  below  the  epithelium,  so  that  it  is  impossible  to 
determine  its  relations  to  the  underlying  connective  tissue.  These 


FIG.  78. — EPITHELIOMA  OF  THE  LIMBUS.      x  6. 

The  growth  is  lens-shaped,  and  consists  almost  entirely  of  epithelium.  Bowman's 
membrane  is  curled  up  at  the  advancing  edge.  There  is  dense  round-celled  infil- 
tration at  the  base. 

tumours  sometimes  show  no  tendency  to  rapid  growth,  remaining  un- 
changed for  a  considerable  period.  There  is  no  question  that  such 
cases  should  be  watched  with  extreme  care.  The  malignancy  seems  to 
vary  irrespective  of  the  microscopical  varieties  of  the  growth. 


THE    CONJUNCTIVA 


143 


Microscopically,  epithelioma  of  the  conjunctiva  differs  little  from 
that  of  other  parts  (Fig.  80).  The  surface  epithelium  grows  down  in 
columns  into  the  stroma,  and  these  columns  divide  and  anastomose, 
forming  a  complex  coarse  network,  separated  from  each  other  by  a 
variable  but  usually  small  amount  of  fibrous  tissue  carrying  blood- 
vessels. In  parts  the  basement  membrane  is  broken  through,  and  the 
cells  shade  off  into  the  stroma,  so  that  in  this  transition  zone  cells  occur 
which  cannot  be  dogmatically  diagnosed  as  either  epidermal  or  meso- 
dermal,  but  partake  of  the  nature  of  each.  The  peripheral  cells  of  the 
bands  correspond  to  the  basal  and  youngest  cells,  and  are  mostly 
cubical  or  cylindrical.  Upon  these  follow  larger  polygonal  cells  with 
interlocking  processes,  snowing  often  beautiful  examples  of  prickle- 


FIG.  79. — EPITHELIOMA  OF  THE  LIMBUS.      x  3. 

From  a  specimen  sent  by  Professor  Fuchs.  The  lid,  fornix,  and  part  of  the  eye 
are  seen.  The  growth  is  entirely  epibulbar,  and  is  infiltrating  the  fornix  and 
Tenon's  capsule. 

cells.  Centrally  the  cells  are  flattened,  and  form  epithelial  pearls  or 
cell-nests,  the  nuclei  disappearing  and  the  cells  becoming  flattened 
and  horny.  The  whole  is  often  pervaded  by  polymorphonuclear 
leucocytes,  and  a  dense  round-celled  infiltration  often  marks  the  limit- 
ing zone  of  the  stroma,  giving  testimony  of  inflammatory  reaction. 

The  nuclei  of  most  of  the  cells  vary  enormously.  Some  are  small, 
with  little  chromatin  ;  others  are  gigantic,  rich  in  chromatin  which  is 
arranged  in  irregular  lumps  (Fig.  80).  In  many  cells  the  nuclei  are 
broken  up  ;  others  are  in  active  karyokinesis,  which  is  often  atypical, 
with  an  odd  number  of  centrosomes,  irregularly  and  unequally  arranged. 
In  some  cells  the  nuclei  are  being  extruded.  Many  present  appearances 
suggestive  of  coccidia,  and  are  considered  by  some,  on  insufficient 


144 


THE    PATHOLOGY   OF  THE    EYE 


FIG.  80. — EPITHELIOMA  OF  THE  LIMBUS.      x  90. 

To  show  the  extraordinary  variety  of  nuclear  forms.     This  figure  should  be 
compared  with  Fig.  81,  which  is  magnified  to  the  same  degree. 


FIG.  Si. — PAPILLOMA  OF  THE  CONJUNCTIVA,      x  90. 

Part  of  Fig.  55  more  highly  magnified,  to  show  the  nature  of  the  epithelium. 
The  stroma  is  infiltrated  with  round-cells,  some  of  which  have  penetrated  between 
the  epithelial  cells. 


THE    CONJUNCTIVA 


145 


grounds,  to  be  in  reality  parasitic  organisms.  The  cells  therefore  show 
much  more  atypical  variation  than  those  found  in  papillomata  (Fig. 
81).  Here  cell-division  results  in  great  hyperplasia,  but  the  resultant 
cells  are  of  almost  normal  type. 

The  corneal  epithelium  usually  passes  on  to  the  growth  un- 
changed. This  is  especially  the  case  with  the  superficial  layers, 
whilst  the  middle  layers  broaden  out  and  become  ten  or  twenty  layers 
thick.  The  conjunctival  epithelium  also '  passes  gradually  into  the 
tumour,  and  here  goblet-cells  are  often  present  in  large  numbers.  The 
cornea  is  invaded  by  the  columns  of  tumour  cells,  which  may  lift  up 
Bowman's  membrane  with  the  epithelium,  so  that  these  pass  for  some 
distance  on  to  the  growth.  Deeper,  fine  columns  of  epithelial  cells 


FIG.  82. — EPITHELIOMA  OF  THE  LIMBUS.      x  8. 

From  a  man  set.  62.  The  spindle-shaped  mass  is  composed  almost  entirely 
of  fibrous  tissue,  containing,  however,  narrow  cords  of  epithelial  cells  one  or  two 
cells  deep. 

invade  the  substantia  propria,  pushing  the  lamellae  apart  and  breaking 
them  up.  Posteriorly,  the  whole  episclera  is  gradually  invaded,  and 
tubules  now  dip  down  in  the  lymph-spaces  between  the  scleral  laminae, 
though  apparently  against  great  resistance.  Sections,  however,  often 
show  islets  of  epithelial  cells  embedded  in  the  sclerotic,  mostly  in  the 
superficial  layers  of  the  anterior  part.  The  growth  may  invade  Tenon's 
capsule,  or  extend  into  the  fornix  and  lid  (Fig.  79). 

In  some  cases  there  is  an  enormous  increase  of  fibrous  tissue  and 
round-celled  infiltration  between  the  corneal  and  scleral  lamellae, 
whilst  the  epithelial  cells  are  few  in  number  and  form  small  islets  or 
chains  in  the  lymph-spaces  (Fig.  82). 

When  the  globe  is  invaded  it  is  along  the  perivascular  and  perineural 
lymph-spaces  of  the  corneo-scleral  junction, — never  elsewhere.  This  is 

10 


146  THE    PATHOLOGY    OF   THE    EYE 

characteristic  of  all  growths  in  this  situation  ;  it  is  the  weak  spot  of  the 
eye,  and  whilst  epibulbar  sarcomata  rarely  penetrate  the  globe,  the 
epitheliomata  do  so  more  frequently.  It  is  here,  too,  that  intra-bulbar 
growths  commonly  become  extra-ocular.  The  epithelial  cells  are 
chiefly  arranged  around  the  perforating  vessels,  and  cling  to  them  so 
that  they  reach  Schlemm's  canal,  which  they  also  surround.  Usually 
the  intima  and  endothelium  of  the  vessels  are  intact,  but  intra-vascular 
epithelial  plugs  are  also  seen.  In  this  manner  the  angle  of  the  anterior 
chamber  is  reached,  and  the  growth  now  infiltrates  the  intra-ocular 
structures.  Cells  may  become  separated  from  the  main  mass  in  the 
anterior  chamber,  as  in  other  lymph-spaces,  and  carried  to  other  parts, 
thus  setting  up  new  foci,  which  are  in  reality  metastases  (cf.  v.  Michel). 

Epitheliomata  of  the  conjunctiva  are  not  infrequently  pigmented, 
Panas  considering  nearly  all  these  melanotic  growths  as  of  epithelial 
origin  (v.  p.  140).  The  epitheliomata  are  not  usually  so  deeply  pig- 
mented as  the  sarcomata.  This  is  explained  for  the  hsematogenous 
pigmentation  by  the  greater  rarity  of  haemorrhages,  due  to  fewer 
vessels,  which  have  normal  walls.  In  the  typical  melanomata  the 
pigment  is  autochthonous,  and  the  cells  are  doubtless  offspring  of  the 
pigmented  cells  which  often  occur  normally  at  the  limbus. 

Peribulbar  epitheliomata  have  been  described  by  Heyder  (two 
cases),  Lagrange  (one  case),  and  Reis  (one  case).  In  Lagrange's  case 
the  globe  was  wholly  embedded  in  the  tumour,  except  part  of  the 
cornea.  The  growth  consisted  of  epithelial  cells,  not  arranged  typically 
as  an  epithelioma  or  as  a  carcinoma.  There  were  no  cell-nests.  It  is 
possible  that  all  these  tumours  were  really  endotheliomata. 

Epithelioma  of  the  conjunctiva,  as  well  as  papilloma,  occurs  as  part 
of  the  general  carcinomatosis  found  in  xeroderma  pigmentosum 
(Greeff). 

VON  GRAEFE. — A.  f.  O.,  vii,  2,  1860.  MANZ. — A.  f.  O.,  xvii,  2,  1878.  NOYES. — 
T.  Amer.  O.  S.,  1882.  SGROSSO. — Ann.  di  Ott,  xxi,  1892.  *  LAGRANGE. — Tumeurs  de 
1'CEil,  i,  Paris,  1901.  *HEYDER. — A.  f.  A.,  xvii,  1887.  PARISOTTI. — Rec.  d'Ophth.,  1885. 
OLIVER. — A.  of  O.,  xxvi,  1897.  TROUSSEAU. — A.  d'O.,  xvi,  1896.  ANDERSON  CRITCHETT 

AND    JULER. T.    O.    S.,    Xi,     1891.       ALTLAND. A.  f.    A.,    xliv,    IQOI.       S\ELL. T.   O.  S.,  XXI, 

1901.     REIS. — K.  M.  f.  A.,  xli,  1903. 


THE    CARUNCLE 

INFLAMMATION 

The  caruncle  may  be  inflamed  with  the  conjunctiva;  in  trachoma 
follicles  may  develop  in  it.  The  sebaceous  glands  in  it  may  be 
affected  with  diseases  common  to  them  elsewhere,  e.  g.  acne ;  and  con- 
cretions may  form  in  them  from  retained  secretion  becoming  impreg- 
nated with  calcium  salts.  Thickening  of  the  caruncle  may  occur  in 
syphilis. 

TUMOURS 
Papillomata  are  the  commonest  tumours  found  here.     They  re- 


THE    CONJUNCTIVA  147 

semble  those  of  the  conjunctiva,  and  often  show  their  origin  by  the 
presence  of  sebaceous  glands  in  the  base  (Fig.  55). 

Lymphangioma  has  the  same  characters  as  in  the  conjunctiva 
(Sachs). 

Adenomata  occur  in  young  people  as  pink  firm  tumours.  They  may 
be  polypoid  or  sessile,  and  grow  very  slowly.  They  are  often  cystic 
(cystadenomata).  Cases  have  been  described  by  Testelin  and  Prudden  ; 
those  of  Fontan  and  Schirmer  apparently  originated  in  the  plica,  and 
therefore  from  vestigial  glands.  The  tubules  and  cysts  are  lined  by  a 
single  layer  of  cylindrical  epithelium,  and  seem  to  be  derived  from  the 
acino-tubular  glands  (sweat-glands). 

Naevus  of  the  caruncle  resembles  that  of  the  conjunctiva.  Gins- 
berg describes  a  tumour  supposed  to  be  derived  from  a  nsevus.  It  was 
composed  of  infiltrated  fibrous  tissue,  with  many  endothelioid  cells 
resembling  naevus  cells,  and  was  covered  by  epithelium  which  sent  pro- 
cesses downwards  into  the  stroma.  Naevi  are  here  particularly  exposed 
to  irritation,  and,  according  to  Wintersteiner,  malignant  growths  de- 
velop in  them  much  more  frequently  than  in  those  of  the  C.  tarsi. 

Dermoids  of  the  caruncle  have  been  described  by  Demours,  Schiess- 
Gemuseus,  Wallenberg,  Wolff,  and  Bock.  The  first  three  were  in  the 
plica,  the  caruncle  being  seen  at  the  inner  border.  In  Bock's  case  the 
tumour  consisted  of  dense  fibrous  tissue,  with  fat,  elastic  tissue, 
medullated  nerves,  unstriped  muscle,  and  sebaceous  glands.  A  few 
hairs  were  present.  The  epithelium  was  partly  a  single  layer  of  cylin- 
drical, and  partly  two  or  three  layers  of  large  cubical  cells,  with  many 
goblet-cells.  This  tumour  may  have  been  a  mere  hyperplasia  or  fibro- 
lipoma,  as  described  by  the  author.  There  is  therefore  no  indisputable 
case  of  dermoid  published. 

Cysts,  apart  from  those  found  in  adenomata,  have  been  found  in 
the  caruncle  and  its  neighbourhood  by  Rumschewitsch,  as  the  result 
of  inflammatory  processes,  e.g.  trachoma.  They  are  retention  cysts 
occurring  in  the  modified  sweat-glands.  They  are  multilocular,  lined 
by  a  single  or  double  layer  of  epithelium,  having  the  usual  character- 
istics of  such  cysts  of  the  conjunctiva. 

Epithelioma  has  been  described  by  Despagnet  and  de  Schweinitz. 

Sarcoma,  pigmented  or  non-pigmented,  is  the  commonest  malignant 
tumour  (Veasey,  Snell,  de  Berardinis).  It  is  usually  small  round- 
celled,  and  telangiectatic  fibre-sarcomata  occur  (del  Monte,  Manthey). 

Carcinoma  is  rarer,  and  springs  from  the  glands  'present. 

Rodent  ulcer  apparently  only  occurs  by  extension  ff  emu  the  lid,  and 
in  this  form  frequently. 

SACHS. — Ziegler's  Beitrage,  v,  1889.  TESTEHN. — Diet,  encycl.  des  Sc.  med.,  art. 
'  Caroncle.'  PRUDDEN. — A.  of  O.,  xv,  1886.  FONTAN. — Rec.  d'O.,  1881.  *SCHIRMER. — 
A.  f.  O.,  xxxvii,  i,  1891.  GINSBERG. — Grundriss  d.  path.  Hist,  des  Auges,  Berlin,  1903. 
WINTERSTEINER. — B.  d.  o.  G.,  1898.  DEMOURS. — Traite,  pi.  Ixiv,  Paris,  1818.  SCHIESS- 
GEMUSEUS. — K.  M.  f.  A.,  xv,  1877  ;  xvi,  1878.  WALLENBERG. — Inaug.  Diss.,  Konigsberg, 
1889.  WOLFF. — K.  M.  f.  A.,  xxix,  1891.  BOCK. — K.  M.f.  A.,  xxiv,  1886.  RUMSCHEWITSCH. 
— K.  M.  f.  A.,  xli,  1903.  DESPAGNET.— Rec.  d'O.,  1888.  DE  SCHWEINITZ.— T.  Am.  O.  S., 
1898.  VEASEY,  SNELL. — A.  of  O.,  xxvi,  1897.  DE  BERARDINIS. — Ann.  di  Ott,  xxxi,  1902. 
DEL  MONTE. — Ann.  di  Ott.,  viii,  1879.  MANTHEY. — Inaug.  Diss.,  Greifswald,  1897. 


CHAPTER    III 
THE     CORNEA 

THE  NORMAL  CORNEA 

THE  cornea  is  the  anterior  portion  of  the  coats  of  the  eyeball,  which 
are  here  specially  differentiated  for  the  transmission  and  refraction 
of  light  rays.  The  conjunctiva  is  reduced  to  a  layer  of  stratified 
epithelium ;  the  sclerotic  is  represented  by  the  substantia  propria,  of 
which  Bowman's  membrane  is  merely  the  anterior  layer,  and  the  uveal 
tract  persists  as  a  single  layer  of  endothelial  cells,  together  with  the 
elastic  membrane  (Descemet's  membrane)  which  is  derived  from  them. 
This  view,  which  was  emphasised  by  Schwalbe,  is  proved  conclusively 
by  embryological  investigations  (Kessler,  Kolliker).  At  the  same  time, 
it  must  be  admitted  that  there  is  some  variation  in  different  animals,  so 
that  Waldeyer  regarded  only  the  central  lamellae  of  the  cornea  as  be- 
longing to  the  sclerotic,  the  anterior  lamellae,  with  Bowman's  membrane 
and  the  epithelium  belonging  to  the  conjunctiva,  and  the  posterior  lamellae, 
with  Descemet's  membrane  and  the  endothelium,  to  the  uveal  tract. 

The  cornea,  viewed  from  in  front,  is  horizontally  elliptical ;  viewed 
from  behind  it  is  circular.  This  is  due  to  the  fact  that  it  is  set  in  the 
sclerotic  like  a  watch-glass  in  its  rim,  and  the  sclera  and  conjunctiva 
both  spread  farther  over  the  cornea  above  and  below. 

The  early  foetal  cornea  is  indistinguishable  from  the  sclerotic,  both 
consisting  of  oblong  connective-tissue  cells  with  little  intra-cellular 
substance.  It  is  vascular  until  the  fifth  month,  after  which  the  vessels 
atrophy.  In  its  foetal  state  it  is  not  only  relatively,  but  absolutely 
thicker  than  it  is  in  adults.  It  gradually  becomes  thinner,  the  central 
part  in  the  adult  being  thinner  than  the  periphery. 

The  embryological  origin  of  the  different  layers  is  important  patho- 
logically, since  conjunctival  affections  frequently  invade  the  corneal 
epithelium,  scleral  the  substantia  propria,  and  uveal  the  endothelium  and 
its  contiguous  layers. 

Blood-vessels  in  the  cornea  are  limited  normally  to  a  narrow  peri- 
pheral zone,  ^ — i  mm.  wide  at  the  sides,  i — 1£  or  at  most  2  mm.  wide 
above  and  below  (Leber).  Here  they  form  a  series  of  minute  loops, 
and  it  is  by  exudation  from  these  that  the  whole  cornea  is  nourished. 

The  epithelium  is  stratified,  consisting  of  several  layers.  The 
basal  cells  are  cylindrical,  and  differ  from  those  of  the  neighbouring 
conjunctiva  in  that  their  nuclei  are  farther  from  the  basement  membrane 
and  do  not  stain  more  deeply  than  those  of  the  other  layers  (Fuchs). 


THE    CORNEA  149 

Moreover  they  do  not  contain  pigment  granules,  such  as  often  occur  in 
the  conjunctiva  of  the  limbus,  and  there  are  no  papillae.  The  cells  of 
the  middle  layer  are  typical  prickle-cells,  so  that  there  are  definite 
lymph-channels  between  them,  such  as  do  not  exist  in  the  conjunctiva. 
The  superficial  cells  are  flattened,  with  oval  nuclei  lying  horizontally. 

The  substantia  propria  consists  of  alternating  lamellae  of  connective 
tissue,  each  made  up  of  bundles  of  fine  fibrillae.  There  are  about  sixty 
lamellae  (Bowman),  which  run  parallel  to  the  surface,  and  cross  at  right 
angles  in  alternate  layers.  They  intercommunicate  frequently,  so  that 
they  cannot  be  stripped  apart  cleanly.  The  bundles  of  fibrils  are 
roundish  in  cross-section,  and  are  bound  together  by  ground-substance. 
By  means  of  injection  under  very  low  pressure,  a  network  of  anasto- 
mosing stellate  spaces  between  the  lamellae  is  obtained.  These  are 
v.  Recklinghausen's  canals.  If  mercury  is  used  and  the  pressure  is 
greater,  tubular  passages  running  at  right  angles  to  one  another  in  the 
different  layers  are  injected  (Bowman's  corneal  tubes).  This  is  seen  even 
better  by  injecting  air,  and  is  due  to  forcible  separation  of  the  lamellae  ; 
the  tubes  stop  at  the  sclerotic,  where  the  tissue  becomes  denser. 
According  to  Leber,  there  are  no  preformed  spaces  between  the  lamellae, 
and  the  circulation  of  fluid  is  entirely  by  diffusion. 

There  are  two  kinds  of  cells  present  between  the  lamellae.  The 
corneal  corpuscles  (Virchow)  or  fixed  corneal  cells  (Cohnheim)  are 
simply  more  highly  differentiated  connective-tissue  cells,  differing  only  in 
being  more  regularly  arranged  than  usual,  owing  to  the  very  regular 
arrangement  of  the  lamellae.  They  are  flat,  stellate  cells  with  long  rami- 
fying processes,  which  anastomose  with  those  of  the  other  cells.  They  lie 
between  the  lamellae,  and  are  surrounded  by  lymph-spaces,  which  also 
communicate  along  the  processes  with  those  of  neighbouring  cells. 
The  nuclei  are  round  or  oval  in  the  new-born,  but  polymorphic  in  the 
adult,  with  several  nucleoli.  The  cytoplasm  is  clear,  except  near  the 
nucleus,  where  it  is  granular. 

There  are  always  wandering  cells  between  the  lamellae  (v.  Reck- 
linghausen),  though  these  are  normally  few  in  number.  They  are 
derived  from  the  peripheral  blood-vessels,  and  are  like  wandering  cells 
elsewhere.  They  are  small  and  of  very  variable  shape,  and  when  fresh 
are  strongly  refractile  and  amoeboid. 

Hamilton  states  that  in  the  kitten  and  probably  in  other  animals  the 
lymph-spaces  are  lined  by  a  distinct  endothelium,  each  cell  having  an 
oval  or  round  nucleus.  Rollet  says  that  this  is  only  found  in  young 
animals.  Hamilton  denies  the  existence  of  the  corneal  corpuscles, 
which  he  considers  are  simply  spaces  filled  with  albuminous  fluid, 
which  causes  precipitation  of  gold  from  gold  chloride.  The  nucleus 
really  belongs  to  an  underlying  bundle  of  fibrous  tissue. 

Bowman's  membrane  is  shown  embryologically  to  be  part  of  the 
substantia  propria,  and  therefore  totally  different  from  Descemet's  mem- 
brane. It  does  not  stain  with  elastic-tissue  stains,  so  that  the  term  "  an- 
terior elastic  lamina"  is  a  misnomer.  It  differs  from  the  other  lamellae 
in  having  no  corneal  corpuscles,  and  by  ordinary  stains  appears  structure- 
less. It  consists,  however,  like  them,  of  fine  connective-tissue  fibres. 

Descemet's  membrane  is  a  homogeneous  elastic  lamina,  the  product 


150  THE    PATHOLOGY    OF  THE    EYE 

of  secretion  of  the  endothelial  cells  covering  its  posterior  surface.  It 
stains  with  Weigert's  elastic-tissue  stain,  acid  orcei'n,  etc.  It  is 
normally  uniformly  thick  in  the  central  parts,  but  increases  slightly  in 
thickness  at  the  periphery.  It  increases  in  thickness  with  age. 

It  is  extremely  delicate  at  the  tenth  week  of  fetal  life,  and  still  very 
delicate  at  the  fourth  month.  Up  to  this  time  Bowman's  membrane 
is  not  yet  visible.  At  the  sixth  month  Bowman's  membrane  is 
distinctly  seen,  and  Descemet's  membrane  is  considerably  wider  than  at 
the  fourth  month  (Treacher  Collins).  It  is  about  5 — 7  /m  thick  soon 
after  birth;  6 — 8  fj.  in  the  middle,  and  10 — 12  m  at  the  periphery,  at 
20 — 30  years  of  age ;  and  10  \i  in  the  middle,  and  15 — 20  p  at  the 
periphery,  in  old  people  (H.  Miiller).  E.  v.  Hippel's  measurements  in 
the  new-born  were  2 — 2'4  fi  after  formol  hardening,  3*6  //  after  Miiller's 
fluid.  De  Vries  obtained  the  following  results: — New-born,  1*5 — 2  /u. ; 
10  years  to  adult  age,  5 — 5*5  fj. ;  59 — 77  years,  6*25 — 8'75  ju.  The 
increase  in  thickness  with  age  bears  no  relationship  to  the  increase  in 
thickness  of  the  whole  cornea.  Faint  lamellation  of  Descemet's  mem- 
brane can  sometimes  be  made  out  in  the  normal  eye,  and  frequently 
under  pathological  conditions. 

Descemet's  membrane  is  covered  posteriorly  by  a  single  layer  of 
endothelial  cells,  which  are  continuous  with  those  which  cover  the 
ligamentum  pectinatum  iridis  and  the  iris.  The  cells  are  flattened 
polygonal  cells  with  distinct  nuclei.  According  to  Smirnow,  and  Nuel 
and  Cornil,  the  cells  are  fibrillar  in  structure,  being  traversed  by  radiating 
bundles  of  fine  fibrils,  which  pass  from  cell  to  cell  across  the  intra- 
cellular  spaces.  These  are  probably  threads  of  protoplasm  ;  they  soon 
disappear  after  death  or  removal  of  the  globe.  They  have  only  been 
found  in  birds. 

The  presence  of  elastic  fibres  in  the  substantia  propria  has  been  the 
subject  of  dispute.  It  has  been  denied  by  Sattler  and  Stutzer,  and 
affirmed  by  Leber,  Kiribuchi,  Prokopenko,  and  Tartuferi.  Kiribuchi 
found  fine  fibrils  by  the  resorcin-fuchsin  method,  and  this  was  confirmed 
by  Prokopenko  by  the  acid-orcei'n  method.  They  were  demonstrated 
in  great  profusion  by  Tartuferi  by  a  silver  impregnation  method. 

The  cornea  is  traversed  by  networks  of  nerve-fibrils,  derived  from  a 
peripheral  annular  plexus,  which  is  supplied  by  40 — 45  nerves  from  the 
ciliary  nerves  (Waldeyer).  The  nerves  retain  their  medullary  sheaths 
for  i — 2  mm.  and  then  form  a.  fundamental  plexus  near  the  anterior  surface 
of  the  substantia  propria.  From  this,  pencils  of  fibrils  pass  towards  the 
centre  of  the  cornea,  interlace,  and  form  a  subepithelial  plexus,  from  which 
minute  varicose  fibrillse  pass  between  the  epithelial  cells  almost  to  the 
surface.  There  are  wider  meshed  networks  in  the  deeper  layers  of  the 
substantia  propria.  The  fibrils  are  surrounded  by  lymph-sheaths,  the 
endothelial  cells  of  which  lie  in  close  relation  to  the  corneal  corpuscles. 
The  nerves  can  be  often  seen  passing  through  Bowman's  membrane. 
They  are  beautifully  displayed  by  gold  chloride,  Ehrlich's  methylene- 
blue  method,  or  the  Golgi  method  (Bach). 

In  old  age  the  cornea  becomes  thinner,  the  lamellae  being  more 
closely  packed  and  the  corpuscles  flatter,  their  nuclei  staining  less 
deeply.  As  a  result  of  these  changes  the  cornea  is  duller,  and  its  refrac- 


THE    CORNEA  151 

tive  index  is  increased,  so  that  it  reflects  oblique  light  more  strongly. 
Other  specific  changes  may  also  occur,  e.  g.  the  formation  of  arcus 
senilis  (q.  v.)  and  hyaline  bodies  upon  Descemet's  membrane  (q.  v.). 

SCHWALBE. — Anat.  des  Sinnesorgane,  Erlangen,  1887.  KESSLER. — Zur  Entwicklung 
des  Auges  der  Wirbelthiere,  Leipzig,  1877.  WALDEYER. — In  G.-S.,  i,  1874.  LEBER. — In 
G.-S.,  ii,  1876.  FUCHS. — A.  f.  O.,  xxxviii,  2,  1892.  BOWMAN. — Lectures,  London,  1849. 
v.  RECKLINGHAUSEN. — Virchow's  Arch.,  xxviii.  HAMILTON. — Text-book  of  Pathology, 
i,  London,  1889.  LEBER. — IX  Internat.  Kongr.,  Utrecht,  1899.  TREACHER  COLLINS. — 
R.  L.  O.  H.  Rep.,  xiv,  1896.  H.  MULLER. — Gesammelte  Schriften,  i,  Leipzig,  1872. 
SMIRXOW. — Internat.  Monatsbl.  f.  Anat.  u.  Phys.,  vii,  1890.  NUEL. — A.  d.  O.,  x,  1890. 
NUEL  AXD  CORNIL. — Arch,  de  Biol.,  x,  1890.  E.  v.  HIPPEL. — A. f.  O.,  xlv.  VRIES. — A.  f.  O., 
liv,  3,  1902.  TARTUFERI. — A.  f.  O.,  Ivi,  3,  1903.  BACH. — A.  f.  A.,  xxxiii,  1896. 


WOUNDS 
UNCOMPLICATED  WOUNDS 

Wounds  of  the  cornea  may  be  partial — involving  only  the  superficial 
layers — or  perforating.  In  uncomplicated  wounds  the  process  of  healing 
is  the  same  in  each  case. 

The  healing  of  simple  wounds  of  the  cornea,  such  as  are  made  by  a 
keratome  or  Graefe's  knife,  have  been  investigated  upon  animals,  chiefly 
rabbits,  by  Giiterbock,  Gussenbauer,  Wyss,  Neese,  Ranvier,  Clarke,  etc. 
The  wound  made  by  a  keratome  or  broad  needle  is  probably  the 
simplest  linear  wound  which  can  be  made,  and  heals  most  rapidly,  the 
loss  of  tissue  and  the  disturbance  of  the  structures  being  minimal.  On 
withdrawing  the  instrument  after  making  a  perforating  wound,  the 
aqueous  escapes.  It  is  rapidly  secreted  again,  but  the  new-formed 
aqueous  differs  from  the  normal  in  containing  a  larger  amount  of  pro- 
teid.1  It  is  now  capable  of  forming  a  fibrinous  coagulum,  and  this  is  of 
importance  in  the  process  of  healing. 

The  wound  is  rapidly  closed  by  the  apposition  of  the  edges.  This 
takes  place  only  in  the  middle  or  slightly  posterior  layers  of  the  sub- 
stantia  propria,  and  is  brought  about  by  the  imbibition  of  fluid  by  the 
corneal  lamellae,  whereby  they  swell,  so  that  the  cut  ends  come  in  con- 
tact. The  area  of  contact  is  greater  in  wounds  which  traverse  the 
cornea  obliquely,  and  the  cohesion  is  thus  increased,  so  that  these 
wounds  are  somewhat  valvular.  The  cohesion  rapidly  becomes  sufficient 
to  withstand  the  intra-ocular  pressure,  so  that  the  anterior  chamber  is 
re-formed.  The  time  which  this  takes  varies  according  to  the  nature 
of  the  wound,  commencing  within  two  minutes  (Clarke),  and  being  com- 
plete within  half  an  hour  in  favourable  cases.  It  may  be  delayed  to  two 
or  three  hours  if  the  animal  is  not  kept  at  rest  (Clarke),  or  even  to  days 
or  weeks  under  unfavourable  conditions.  Under  these  circumstances 
the  nutrition  of  the  cornea  is  liable  to  suffer. 

At  the  anterior  and  posterior  surfaces  the  wound  gapes,  owing  to  the 
normal  elasticity  of  the  tissues,  which  retract,  leaving  anterior  and  pos- 
terior triangular  areas,  the  apices  of  which  are  directed  towards  the  co- 
herent part.  The  anterior  edges  usually  project  considerably  above  the 

1  See  PARSONS,  The  Ocular  Circulation,  London,  1903. 


152 


THE    PATHOLOGY   OF  THE    EYE 


surface  of  the  cornea,  the  resistance  to  swelling  of  the  tissues  being  least 
here  (Fig.  83).  The  swelling  is  also  partly  due  to  tears.  The  anterior 
triangle  is  quickly  filled  with  epithelium  (twenty-four  hours).  This  is 
not  due  to  epithelium  being  carried  in  by  the  knife  (Giiterbock),  since 
no  epithelium  is  present  at  first,  but  the  edges  are  covered  in  from  twelve 
to  fifteen  minutes.  The  process  is  probably  at  first  simply  mechanical 
(Ranvier).  The  epithelial  cells  are  normally  in  a  state  of  tension,  and 
when  this  is  released  movement  takes  place  in  the  direction  of  least 
resistance.  This  view  is  supported  by  the  fact  that  mitotic  figures  are 
absent  from  the  cells  in  the  depression  at  this  stage,  and  only  occur  here 
late  and  sparsely,  though  this  may  be  accounted  for  to  some  extent  by 
direct  cell-division,  which  takes  place  in  epithelium  which  is  dividing 
rapidly.  Karyokinesis  occurs  first  a  short  distance  around  the  wound, 
and  later  in  still  more  peripheral  parts  (Neese).  This  doubtless  increases 
the  tension  of  the  cells  where  it  occurs,  and  tends  to  push  the  older  cells 


FIG.  83. — WOUND  OF  CORNEA. 

Fuchs,  T.  O.  S.,  xxii.     Swelling  of  the  lips  of  the  wound  through  imbibition 
of  fluid  by  the  lamellae. 

into  the  wound.  Still  later,  in  about  twelve  hours,  mitoses  are  found 
in  the  epithelium  filling  the  wound  itself.  Peters  described  amoeboid 
movements  in  the  cells  at  the  edges,  but  this  observation  has  not  been 
confirmed.  The  ingrowth  of  epithelium  ends  usually  in  about  twenty- 
four  hours,  after  which  a  process  of  consolidation  sets  in.  The  apex  of 
the  anterior  triangle  is  often  half  or  two-thirds  of  the  way  through  the 
cornea. 

Weinstein's  results  differ  from  those  here  described.  He  found 
mitoses — always  in  the  cylindrical  cells — as  early  as  one  hour  after  the 
operation.  They  occurred  at  a  very  considerable  distance  from  the 
wound.  In  three  hours  mitoses  were  very  numerous,  and  were  found 
very  near  the  wound,  but  not  actually  at  the  edge.  In  four  hours  they 
were  found  within  the  anterior  triangle,  as  well  as  near  the  wound,  and 
indeed  over  the  whole  surface  of  the  cornea.  At  this  stage  cell-division 
is  at  its  height.  Direct  cell-division  (Nussbaum^Marchand)  was  not 
observed. 


THE   CORNEA 


153 


The  posterior  triangle  is  smaller,  and  similarly,  though  more  slowly, 
filled  with  the  endothelium  (Schottlander,  Peters).  Descemet's  mem- 
brane is  more  elastic,  and  therefore  retracts  more  than  any  other 
part  of  the  cornea.  The  cut  ends  curl  up  into  a  spiral,  which  is  directed 
forwards,  the  anterior  surface  of  the  membrane  retracting  most.  The 
endothelial  cells  are  carried  into  the  wound,  and  form  heaps  of  cells 
at  the  edges.  Small  wounds  are  covered  in  three  or  four  days,  larger 
ones  in  seven  days.  There  are  no  mitotic  figures  for  six  days,  and  they 
are  not  numerous  until  ten  days  and  later ;  they  are  found  chiefly  near 
the  periphery  of  the  wound. 

On  the  second  day  Weinstein  found  shapeless  cell-masses  on  the 
convex  surface  of  the  ends  of  Descemet's  membrane.  No  nuclei  could 
be  seen  in  them,  but  they  stained  deeply  with  hsematoxylin.  On  the 
third  day  spindle-shaped  cells  were  seen  along  the  posterior  surface  of 


FIG.  84. — WOUND  OF  CORNEA,      x  55. 

Healed  iridectomy  wound.  The  disturbance  of  parts  is  minimal.  In  the  lower 
half  there  is  extremely  little  scar  tissue.  The  upper  half  contains  more  scar  tissue, 
and  is  infiltrated  with  round-cells. 

the  wound.  These  gradually  increased  in  numbers  until  they  formed  a 
long  band,  uniting  the  ends  of  Descemet's  membrane.  There  were  also 
some  shorter,  larger  cells,  with  well-formed  nuclei,  often  showing 
mitotic  figures.  They  lay  on  the  spindle-cells,  projecting  into  the 
anterior  chamber.  All  these  cells  are  probably  of  endothelial  origin. 

Two  processes  therefore  occur  both  in  the  epithelium  and  the 
endothelium :  (i)  a  provisional  covering  of  the  wound  with  old  cells ; 
followed  by  (2)  regeneration  by  karyokinesis,  and  ultimate  consolidation 
(Peters). 

The  cut  ends  of  Descemet's  membrane  never  unite,  but  in  the  course 
of  time  a  new  cuticular  membrane  may  be  formed  by  the  activity  of  the 
endothelial  cells  (Gepner,  Wagenmann).  In  Wagenmann's  case  the 
new  membrane  was  about  one-fourth  the  thickness  of  Descemet's 
membrane  in  two  and  a  quarter  years. 


154 


THE    PATHOLOGY   OF   THE    EYE 


It  may  ultimately  become  as  thick  as  the  normal  membrane,  and 
even  fuse  with  it ;  but  if  the  ends  of  the  latter  are  curved  forwards  it 
fuses  with  the  convex  surface,  so  that  Descemet's  membrane  appears  to 
split.  There  are  often  several  irregular  cuticular  membranes  formed, 
each  being  generally  covered  by  a  layer  of  endothelium.  Descemet's 
membrane  then  seems  to  split  into  several  layers.  They  are  usually 
thinner  than  the  normal  membrane. 

O.  Becker  found  the  cut  ends  of  Descemet's  membrane  still  ununited 
in  a  scar  after  six  years,  and  Neese  experimentally  confirmed  the  fact 
that  they  do  not  unite.  Weinstein  found  the  first  signs  of  a  new 
hyaline  membrane  four  weeks  after  the  operation.  It  was  extremely 
thin  even  after  two  months,  and  was  about  half  the  thickness  of  the 


FIG.  85. — WOUND  OF  CORNEA,      x  55. 

Wound  with  a  fragment  of  steel,  which  was  removed  by  Haab's  magnet.  Wound 
depressed;  iris  adherent.  Bowman's  membrane  is  curled  up.  The  scar  tissue  binds 
the  lamellae  together,  and  sends  short  conical  processes  between  them.  The  retracted 
cut  ends  of  Descemet's  membrane  are  well  seen.  The  inflamed  iris  stroma  is  seen 
below. 

normal  Descemet's  membrane  after  three  to  three  and  a  half  months. 
In  four  months  it  nearly  reached  the  normal  thickness.  The  new 
membrane  sprang  from  the  convex  surfaces  of  the  cut  ends  of 
Descemet's  membrane,  but  was  continuous  with  the  ends  in  rare  cases 
in  which  these  were  very  little  bent  forwards.  Both  membranes 
stained  equally  with  Weigert's  resorcin-fuchsin  stain.  The  anterior 
half  of  the  new  membrane  often  showed  fine  striation  longitudinally. 
Weinstein  combats  the  theory  of  Ranvier,  Wagenmann,  etc.,  that 
Descemet's  and  the  new  membrane  are  the  product  of  the  endothelial 
cells.  He  regards  them  as  differentiated  corneal  lamellae  which  have 


THE   CORNEA  155 

undergone  hyaline  changes  under  the  influence  of  the  aqueous  fluid. 
The  impermeability  of  the  normal  endothelium  to  the  aqueous  would 
seem  to  negative  this  view. 

The  substantia  propria  never  regenerates;  it  is  replaced  by  scar 
tissue.  The  ends  of  Bowman's  membrane  are  slightly  retracted,  or 
may  ultimately  override  one  another,  or  be  convoluted,  through  the 
contraction  of  the  scar  tissue  (Fig.  85).  The  lamellae  are  not 
always  in  contact  even  in  the  middle ;  they  are  then  separated  by  a 
fibrinous  coagulum  containing  very  few  leucocytes.  Apart  from 
cedematous  swelling  of  the  ends  of  the  lamellae  and  the  neighbouring 
corneal  corpuscles,  there  are  no  changes  in  the  early  stages.  Later, 
the  corneal  cells  proliferate  into  the  clot  and  into  the  epithelium,  which 
they  push  upwards  towards  the  surface.  The  new  cells  are  small  and 
spindle-shaped,  in  no  way  differing  from  the  embryonic  connective- 
tissue  cells  of  granulation  tissue.  From  these,  fibrous  tissue  fibrillae 
are  formed,  running  in  irregular  bundles — horizontal,  oblique,  and 
vertical.  As  time  goes  on  the  bundles  become  more  horizontal,  con- 
forming to  the  general  direction  of  the  corneal  lamellae,  the  cells 
diminish  in  number,  and  a  compact  scar  is  formed  (Figs.  84,  85).  This 
dwindles  more  and  more  by  the  contraction  of  the  scar  tissue,  but  never 
entirely  disappears.  The  younger  the  cornea,  the  more  does  the  scar 
approximate  to  the  structure  of  the  normal  tissue.  Finally,  the 
epithelium  is  lifted  up  almost  or  quite  to  its  normal  level,  and  only  a 
inear  cicatrix  remains  (Fig.  85). 

Weinstein  found  that  the  fibrinous  coagulum  filling  the  wound 
played  no  active  part  in  the  healing  process,  but  formed  merely  a  tem- 
porary plug,  and  a  framework  for  the  wandering  cells  and  histogenetic 
elements.  After  three  or  four  hours'  deeply  staining,  spindle-cells  with 
very  dark  thin  linear  nuclei  are  seen  in  the  substantia  propria  near  the 
wound.  These  often  form  chains,  two,  three,  or  four  in  a  row.  The 
author  is  doubtful  as  to  their  origin,  and  quotes  Ballowitz,  who  never 
observed  mitosis  in  the  normal  corneal  corpuscles.  They  are  most 
probably  leucocytes,  which  Weinstein  states  were  entirely  absent.  He 
observed  mitoses  in  the  fixed  corpuscles,  but  not  until  the  second  day. 
They  occurred  in  spindle-  and  club-shaped  cells  close  to  the  wound,  and 
increased  in  numbers,  so  that  by  the  fifth  or  sixth  day  the  wound  was 
filled  with  young  spindle-cells.  The  process  goes  on  with  varying 
rapidity  in  different  wounds,  and  in  different  parts  of  the  same  wound. 

Weinstein  describes  vacuolation  and  degeneration  of  the  epithelial 
cells  of  the  anterior  triangle  as  regeneration  of  the  substantia  propria 
proceeds.  Many  nuclei  shrink,  and  the  cells  break  down,  forming  round 
or  oval  spaces.  Groups  of  epithelial  cells  may  become  entangled  in  the 
granulation  tissue.  These  processes  obviously  assist  the  restoration  of 
the  normal  disposition  of  the  parts. 

Masugi  has  also  investigated  the  subject,  especially  from  the  point 
of  view  of  the  effect  of  cocain  on  the  regenerative  processes.  He  con- 
firms most  of  the  results  of  earlier  observers,  and  finds  further  that 
cocain  has  a  deleterious  effect  upon  the  cells,  diminishing  karyokinesis. 

Vossius. — A.  f.  O.,  xxvii,  3,  1881.  GUTERBOCK. — Virchow's  Archiv,  1,  1870.  GUSSEN- 
BAUER. — Arch.  f.  klin.  Chir.,  xii.  LOTT. — Med.  Centralblatt,  xxxvii,  1870.  WYSS. — 


156  THE    PATHOLOGY    OF   THE    EYE 

Virchow's  Archiv,  Ixix,  1877.  NEESE. — A.  f.  O.,  xxxiii,  i,  1887.  PETERS. — Inaug.  Diss., 
Bonn,  1885.  RANVIER. — Comptes  rendus,  1896,  1897,  1898 ;  Arch.  d'Anat.  micr.,  1898. 
SCHOTTLANDER. — Arch.  f.  mikr.  Anat.,  xxxi.  PETERS. — Arch.  f.  mikr.  Anat,  xxxiii.  GEPNER. 
— A.  f.  O.,  xxxvi,  4,  1890.  WAGENMANN. — A.  f.  O.,  xxxvii,  2,  1891.  CLARKE. — T.  O.  S., 
xviii,  1898.  MASUGI. — K.  M.  f.  A.,  xxxix,  1901.  FUCHS. — T.  O.  S.,  xxii,  1902.  *WEIN- 
STEIN. — A.  f.  A.,  xlviii,  1903. 

COMPLICATED  WOUNDS 

Wounds  of  the  cornea  are  often  accompanied  by  striatc  opacities 
(q.  v.),  and  less  commonly  by  so-called  filamentary  keratitis  (q.  v.). 

The  most  frequent  complication  is  the  intrusion  of  some  foreign 
body  between  the  lips  of  the  wound.  This  is  usually  either  the  iris, 
lens  fibres  or  capsule,  or  the  vitreous  ;  rarely  cilia,  etc.,  or  the  detached 
retina. 

The  iris. — When  a  perforating  wound  or  ulcer  lies  in  front  of  the 
iris,  the  latter  is  liable  to  be  carried  into  the  wound  by  the  sudden 
outward  rush  of  aqueous  (Fig.  86).  The  prolapse  of  iris  may  be 
partial  or  complete,  a  knuckle  of  iris  protruding  for  a  variable  distance 
into  the  posterior  part  of  the  wound,  or  the  iris  hanging  free  with  the 
pupillary  border  outside  the  wound.  If  the  iris  is  for  some  time  in 
contact  with  the  wound,  adhesion  takes  place,  and  an  anterior  synechia 
is  formed.  The  adhesion  is  at' first  by  means  of  exudate  ;  later,  as  the 
process  of  cicatrisation  proceeds,  the  iris  becomes  anchored  to  the 
cornea  by  new-formed  fibrous  tissue.  In  course  of  time  the  iris  stroma 
atrophies  at  the  point  of  attachment,  and  is  replaced  by  scar  tissue, 
the  retinal  epithelium  alone  persisting  for  a  long  period. 

The  anterior  synechia  of  the  iris  need  not  necessarily  be  exactly 
at  the  site  of  the  wound,  but  is  always  in  its  immediate  vicinity.  The 
endothelium  of  Descemet's  membrane  is  then  absent  at  the  site  of 
adhesion,  and  is  replaced  by  layers  of  long  spindle-shaped  cells  with 
rod-shaped  nuclei ;  these  cells  are  modified  endothelial  cells.  They 
often  fill  the  angles  between  the  iris  and  Descemet's  membrane.  The 
endothelium  covering  the  anterior  surface  of  the  iris  is  liable  to  form  a 
hyaline  cuticular  membrane  upon  its  surface  when  subjected  to  the 
chronic  irritation  induced  by  the  synechia,  so  that  in  old  synechiae 
Descemet's  membrane  may  appear  to  pass  on  to  the  surface  of  the 
iris,  or  to  split  at  the  edge  of  the  adhesion,  one  part  being  the  true 
membrane,  the  other  the  new-formed  one  (Fig.  89). 

Other  structures  besides  the  iris  may  adhere  to  the  back  of  the 
cornea  after  perforating  wounds,  such  as  the  lens  (Fig.  94),  vitreous 
(Fig.  88),  or  retina.  Such  cases  are  rarer,  and  are  usually  accom- 
panied by  anterior  synechia  of  the  iris  ;  indeed,  there  is  generally  an 
anterior  staphyloma.  In  the  case  of  the  lens  there  is  usually  a 
traumatic  cataract ;  the  capsule  is  ruptured  and  lies  convoluted  in  or 
near  the  wound  (Figs.  86,  91,  92).  The  lens  is  usually  cataractous 
throughout,  and  is  invaded  by  fibroblasts  at  the  site  of  injury.  These 
subsequently  form  scar  tissue,  and  tie  down  the  lens  firmly  to  the  cornea. 

Adhesion  of  the  vitreous  can  only  occur  after  dislocation  or  removal 
of  the  lens  (Fig.  88).  The  vitreous  becomes  invaded  with  young 
connective-tissue  cells  from  the  cornea,  and  these  radiate  from  the 


THE   CORNEA 


157 


FIG.  86. — WOUND  OF  CORNEA,      x  28. 

Peripheral  wound,  with  prolapse  of  iris.  The  central  iip,  which  is  covered 
by  epithelium,  overrides  the  peripheral,  to  which  the  iris  is  adherent.  The  lens 
capsule  is  prolapsed  into  the  wound.  Below  on  the  right  the  ciliary  processes  are 


FIG.  87. — WOUND  OF  CORNEA,     x  8. 

Wound  in  centre  of  cornea  sixteen  years  ago.  Corneal  scar,  with  thinning  of 
epithelium,  showing  "levelling  tendency."  Absorption  of  centre  of  lens,  and 
bombe  iris.  The  pupil  is  occluded  with  vascular  fibrous  tissue,  which  stretches 
forwards  to  the  back  of  the  cornea.  Here  the  endothelium  has  proliferated,  and 
grown  down  over  the  fibrous  tissue,  subsequently  producing  a  hyaline  membrane. 
The  dark  spots  in  the  lens  are  due  to  calcification. 


158 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  88. — WOUND  OF  CORNEA,      x   io-5. 

Old  perforating  wound.  The  figure,  which  does  not  pass  through  the  actual 
wound,  shows  anterior  synechia  of  iris  and  vitreous.  The  mass  consists  of  loose 
fibrous  tissue  containing  iris  stroma,  with  many  branched  chromatophores.  Note 
oedema  of  corneal  epithelium. 


FIG.  89. — WOUND  OF  CORNEA,      x  20. 

Wound  of  cornea  with  inclusion  of  a  knuckle  of  iris;  the  scar  has  stretched, 
producing  the  appearance  of  a  ciliary  staphyloma.  Note  the  "  ectropion  of  uvea  "' 
and  folding  of  the  cut  Descemet's  membrane,  which  appears  to  split  at  the  false 
angle,  a  new  delicate  hyaline  membrane  passing  over  the  iris  from  it  to  the  edge 
of  the  out-turned'retinal  pigment.  Descemet's  and  the  new  membrane  have  a  single 
layer  of  endothelium. 


THE    CORNEA 


159 


adhesion,  being  most  numerous  at  this  site.  The  microscopical 
structure  of  the  vitreous  under  these  conditions  very  nearly  resembles 
that  of  cyclitic  membranes,  bands  of  fibrous  tissue  radiating  backwards, 
gradually  becoming  more  and  more  attenuated.  They  consist  chiefly 
of  long  spindle-shaped  cells  with  elongated  oval  nuclei,  lying  amidst 
extremely  delicate  fibrillse.  In  these  cases  also  the  endothelium  of 
Descemet's  membrane  often  grows  on  to  the  new  tissue,  and  subse- 
quently forms  a  hyaline  membrane.  Endothelial  cells  are  also  found 
scattered  amongst  the  fibres. 

In  a  partial  prolapse  of  iris,  a  knuckle  of  iris  projects  into  the  wound, 
and  may  appear  upon  the  surface  as  a  grey  or  brown  prominence 
(Fig.  89).  The  anterior  surface  of  the  iris  becomes  fused  with  the 


FIG.  90. — CYSTOID  CICATRIX.      x   17. 

Six  months  after  iridectomy  for  glaucoma.  The  projecting  lower  lip  consists 
of  corneal  lamellae,  little  changed,  covered  on  both  sides  by  the  iris,  only  slightly 
atrophic.  The  bay  consists  of  conjunctiva,  lined  by  much  atrophied  iris,  little  but 
the  retinal  epithelium  persisting.  The  iris  is  adherent  to  the  anterior  lip,  but  not 
to  the  cornea  anterior  to  this. 

edges  of  the  wound  exactly  as  in  the  case  of  a  simple  anterior  synechia. 
Any  portion  which  projects  above  the  surface  of  the  cornea  becomes 
covered  with  a  layer  of  exudate,  over  which  the  epithelium  grows 
with  extreme  rapidity,  so  that  it  is  usually  covered  in  about  twenty- 
four  hours.  The  exudate  is  replaced  by  granulation  tissue,  which  at 
first  forms  grey  stripes.  The  contraction  of  the  new-formed  fibrous 
tissue  tends  to  flatten  the  prominence,  and  a  firm  grey  scar  may  result. 
In  other  cases  the  scar  tissue  is  not  strong  enough  to  withstand  the 
intra-ocular  pressure,  and  a  cystoid  cicatrix  is  formed  (Fig.  go),  the 
wall  consisting  of  epithelium,  a  thin  layer  of  scar  tissue,  and  the  retinal 
pigment  layer  of  the  iris.  The  scar  tissue  is  often  so  thin  that  the 
cicatrix  looks  black. 


160  THE    PATHOLOGY   OF   THE    EYE 

If  the  iris  fills  only  the  posterior  part  of  the  wound,  the  anterior 
part  may  cicatrise  in  the  usual  manner,  most  of  the  cells  being  directed 
vertically,  their  union  with  the  iris  being  looser  than  with  the  corneal 
lamellae.  In  this  case  also  cystoid  spaces  may  be  formed,  but  they  are 
now  situated  anterior  to  the  iris,  and  have  the  retinal  pigment  upon 
their  posterior  surface,  thus  differing  from  the  cystoid  cicatrix,  which 
is  merely  an  outlying  bay  of  the  anterior  chamber,  covered  anteriorly 
by  the  retinal  pigment. 

In  complete  prolapse  of  the  iris,  and  in  extensive  partial  prolapse,  the 
pigment  epithelium  also  breaks  down,  the  pigment  granules  are  taken 
up  by  leucocytes  and  also  float  free  in  the  lymph-spaces.  Some  are 


FIG.  91. — PERFORATING  WOUND  OF  CORNEA,      x  25. 

Five  weeks  after  removal  of  chip  of  steel  by  Haab's  magnet.  Cornea  retracted 
at  wound.  Bowman's  membrane  folded;  triangular  space  in  back  of  cornea  filled 
in  with  new  fibrous  tissue,  which  also  anchors  up  the  lens  capsule,  and  thus  pulls 
forward  the  iris.  The  lens  capsule  seen  in  the  figure  is  filled  with  red  corpuscles  ; 
below  and  to  the  left  of  it  are  lens  fibres. 

carried  into  the  epithelium,  where  they  lie  both  between  and  in  the 
cells.  Other  masses  of  pigment  become  permanently  embedded  in  the 
scar,  and  apparently  undergo  little  change  after  many  years. 

Fragments  of  iris  may  heal  into  the  wound  with  but  little 
inflammatory  reaction  (cf.  lens  capsule,  p.  161).  Wounds  with  anterior 
synechiae  or  prolapsed  iris  are,  however,  a  constant  source  of  danger. 
Every  movement  of  the  iris  drags  upon  the  ciliary  body,  owing  to  the 
firm  anterior  attachment,  and  this  may  lead  to  ciliary  irritation. 
Moreover  the  consolidation  of  the  scar  is  interfered  with,  so  that  a 
weak  spot  is  left,  which  is  vulnerable  to  both  mechanical  and  bacterial 
agencies. 

The  lens  and  vitreous. — Lens  fibres  (Fig.  92)  and  vitreous  intruded 


THE    CORNEA 


161 


between  the  lips  of  the  wound  delay  union,  and  are  a  source  of  danger, 
since  they  form  a  track  along  which  infection  from  the  conjunctival  sac 
may  travel.  They  are  partly  cast  off  into  the  sac  and  partly  absorbed. 
The  granulation  tissue  invades  them,  and  eventually  they  are  replaced 
by  scar  tissue  (Fig.  91). 

The  lens  capsule  is  much  more  dangerous  (Fig.  92).  It  is  always 
convoluted,  and  appears  to  be  of  irregular  thickness  in  sections,  owing 
to  the  different  directions  in  which  it  is  cut.  It  is  always  surrounded 
by  marked  lymphocytic  infiltration,  showing  severe  inflammatory 
reaction.  This  is  liable,  in  the  course  of  time,  to  attack  the  deeper 
parts  of  the  eye,  leading  especially  to  cyclitis.  It  occurs  in  the  ab- 
sence of  bacterial  infection,  inoculation  and  culture  showing  the  eye 


FIG.  92. — WOUND  OF  CORNEA,      x  25. 

Iridectomy  for  acute  glaucoma  ;  lens  wounded  ;  no  iridectomy  effected ;  pro- 
lapse of  lens  and  vitreous ;  large  subchoroidal  haemorrhage.  The  wound  is  filled 
with  folded  capsule  containing  swollen  lens  fibres.  The  iris  lies  against  the  cornea 
below,  and  behind  this  are  ciliary  processes,  pushed  forwards,  folded  lens  capsule, 
and  detached  choroid  containing  blood.  To  the  right  of  the  wound  are  iris  pigment 
and  extravasated  blood. 

to  be  sterile.  The  irritation  is  probably  due  to  the  extreme  resistance 
of  the  capsule  to  absorption,  whereby  the  healing  of  the  wound  is 
delayed,  and  satisfactory  consolidation  is  indefinitely  postponed.  The 
granulation  tissue  around  the  capsule  is  often  redematous,  and 
frequently  contains  cystic  spaces.  A  more  acute  inflammation  is  not 
infrequently  set  up  by  bacterial  infection  along  the  spongy  track,  and 
the  eye  is  lost  by  panophthalmitis. 

The  ciliary  body. — When  the  wound  is  very  peripheral,  as  in 
some  iridectomies  for  glaucoma,  etc.,  the  ciliary  processes  may  prolapse 
through  the  wound  (Fig.  93).  These  can  scarcely  be  called  corneal 

i  i 


162  THE    PATHOLOGY   OF   THE    EYE 

wounds,  as  they  occur  in  the  sclera  just  posterior  to  the  corneo-scleral 
margin.  They  behave,  however,  in  much  the  same  way  as  corneal 
wounds.  The  prolapsed  ciliary  processes  become  adherent  to  the 
posterior  lip  of  the  wound,  and  usually  retard  healing.  Moreover,  the 
ciliary  body  is  thus  exposed  to  grave  danger  from  infection,  and  the 
complication  must  be  regarded  as  one  of  the  most  serious  which  can 
attend  an  iridectomy.  Such  eyes  usually  demand  excision  on  account  of 
the  dangers  of  sympathetic  ophthalmia, — and  that  before  consolidation 
of  the  scar  has  had  time  to  occur.  Hence  we  usually  see  little  evidence 
of  the  process  of  repair,  intense  inflammatory  reaction  being  the  most 
noticeable  feature. 

Cilia,  etc. — Cilia  and  other  foreign  bodies  may  be  carried  into  the 
wound ;  they  may  rarely  be  inert,  inducing  no  marked  inflammatory 
reaction.  Cases  of  cilia  in  the  cornea  have  been  described  by  Alt, 
Schwarz,  and  others.  Most  frequently  they  set  up  inflammatory  reaction, 
the  irritation  being  shown  by  the  development  of  giant-cells,  usually 


FIG.  93. — PROLAPSE  OF  CILIARY  BODY. 

From  Treacher  Collins,  Researches.  Glaucoma  of  two  months'  standing ; 
section  very  peripheral.  Prolapse  of  ciliary  body ;  escape  of  lens  the  day  after 
operation. 

typical  myeloplaques    (Schwarz).      If  the  root-sheath  is  present,  the 
epithelial  cells  proliferate,  forming  pearl  tumours  or  cysts  (v.  infra). 

ALT. — Lectures  on  the  Human  Eye,  New  York,  1880.     SCHWARZ. — A.  f.  O.,  xlvii,  1898. 

The  retina.  —  In  operations  upon  glaucomatous  eyes  the  retina 
may  become  detached  and  may  prolapse  into  the  wound.  Such  eyes 
are  usually  excised  before  the  wound  has  had  time  to  heal.  After 
expulsion  of  the  lens  the  retina  may  become  adherent  to  the  back  of 
the  corneal  scar. 

If  a  perforating  wound  is  opposite  the  pupil,  it  cannot  be  covered 
by  iris.  In  such  cases  adhesion  of  the  lens  may  occur  (Fig.  94). 
More  commonly  the  wound  heals  slowly  by  outgrowth  of  cicatricial 
tissue  from  the  margins  of  the  opening.  Sometimes  the  plug  of 
exudate  or  the  delicate  granulation  tissue  blocking  the  wound  is 
displaced,  either  by  the  rising  intra-ocular  tension,  or  generally  by 
improper  behaviour  of  the  patient.  This  may  occur  repeatedly,  and 
ultimately  the  perforation  may  remain  permanently  open,  and  a  corneal 
fistula  is  formed.  According  to  Czermak,  the  formation  of  a  fistula  is 


THE   CORNEA  163 

aided  by  adhesion  of  the  pupillary  border  of  the  iris  to  the  edge  of  the 
wound.  Every  dilator  action  then  pulls  upon  the  granulation  tissue, 
which  is  unable  to  consolidate.  It  becomes  loose  and  spongy,  rilled 
with  cystic  spaces,  and  covered  only  by  epithelium,  which  is  also 


FIG.  94. — PERFORATION  OF  THE  CORNEA. 

From  Lawson,  after  Priestley  Smith.     The  iris  is  adherent  to  the  cornea,  and 
there  is  a  ring  posterior  synechia ;  the  lens  is  adherent  to  the  pseudo-cornea. 

vacuolated  and  redematous.  There  is  grave  danger  in  these  cases  of 
the  epithelium  growing  down  along  the  sides  of  the  wound  into  the 
anterior  chamber  or  on  to  the  iris.  Such  growth  will  definitely 
prevent  cicatrisation  of  the  wound,  and  the  fistula  will  be  permanent 


FIG.  95. — WOUND  OF  CORNEA,     x  60. 

Perforating  corneo-scleral  wound  six  days  after  injury.  One  edge  overrides 
the  other,  the  interposition  of  epithelium  having  prevented  union.  The  epithelium 
and  lamellae  are  cedematous,  the  latter  being  swollen,  so  that  their  contours  are 
indistinct. 

unless  it  is  removed.     It  has    never   been    observed    pathologically, 
except  when  the  iris  has  been  adherent. 

CZERMAK. — A.  f.  O.,  xxxvi,  2,  1890;  xxxvii,  2,  1891. 


164 


THE   PATHOLOGY   OF   THE    EYE 


FIG.  96. — WOUND  OF  CORNEA. 

Fuchs,  T.  O.  S.,  xxii ;  see  also  Meller,  A.  f.  O.,  Hi.  Four  days  after  cataract 
extraction.  Downgrowth  of  epithelium  over  edges  of  wound  and  between 
Descemet's  membrane  and  the  substantia  propria. 


FIG.  97. — EPITHELIUM  IN  ANTERIOR  CHAMBER,     x  28. 

From  a  man  set.  70.  November  4th,  1899,  preliminary  iridectomy ;  January 
24th,  1900,  extraction;  January  I2th,  1901,  needling;  July  23rd,  1902,  excision. 
The  eye  was  regarded  as  dangerous  and  likely  to  set  up  sympathetic  inflammation, 
though  there  was  no  k.  p.  in  the  other  eye.  It  is  interesting  to  note  that  there  are 
nodular  aggregations  of  lymphocytes  in  the  iris  and  ciliary  body.  There  is  an 
anterior  synechia,  densely  infiltrated  with  lymphocytes  ;  it  is  invaginated  by  a  fold 
of  epithelium,  which  extends  along  the  back  of  Descemet's  membrane.  Note  the 
new  hyaline  membrane,  covered  with  endothelium,  on  the  inner  surface  of  the 
epithelium ;  the  appearance  of  splitting  of  Descemet's  membrane  is  seen  at  the 
extreme  anterior  part  of  the  figure. 


THE    CORNEA 


165 


In  some  cases  of  wound  of  the  cornea  or  limbus,  e.  g.  cataract 
extraction  or  iridectomy,  the  edges  do  not  lie  in  complete  apposition 
(Fig.  95).  The  normal  pushing  inwards  and  subsequent  proliferation 
of  epithelium  is  then  liable  to  be  more  extensive  (Fig.  96).  The 
epithelium  grows  in  over  both  edges  of  the  wound,  and  may  pass  down 
into  the  anterior  chamber,  and  even  cover  the  back  of  the  cornea  and 
pass  on  to  the  iris  (Fig.  97),  finally  lining  the  chamber  completely 
(Fig.  98).  The  process  is  extremely  rapid :  Meller  quotes  a  case  in 
which  both  sides  of  an  extraction  wound  were  covered  in  four  days. 
On  reaching  the  back  of  the  cornea  the  epithelium  insinuates  itself 
between  Descemet's  membrane  and  the  substantia  propria,  and  also 
grows  on  to  the  posterior  surface.  A  variable  number  of  layers  of  cells 
is  formed,  the  lowest  cells  being  cylindrical  or  cubical,  the  highest  very 


ff* 


FIG.  98. — EPITHELIUM  LINING  ANTERIOR  CHAMBER. 

Fuchs,  T.  O.  S.,  xxii ;  see  also  Meller,  A.f.  O.,  Hi.  Several  years  after  cataract 
extraction.  Downgrowth  of  epithelium  into  the  anterior  chamber,  covering  iris, 
Descemet's  membrane,  etc.  There  is  a  small  epithelial  cyst  in  the  iris ;  this  is 
merely  the  blind  end  of  the  epithelial  invagination.  L,  limbus ;  Ho,  corneo-scleral 
junction  ;  Hu,  cornea  below  wound ;  D,  Descemet's  membrane  ;  J ' ,  iris ;  K,  retinal 
pigment  epithelium;  b,  epithelium  on  iris. 

flat  and  long.  The  same  applies  when  the  iris  is  covered  or  the  whole 
chamber  lined  ;  the  epithelium  varies  extremely  in  thickness,  from  a 
single  layer  to  five  or  six  or  more,  and  the  cells  are  often  ill-formed ;  some- 
times they  can  be  distinguished  from  endothelial  cells  only  with  difficulty. 
Often  these  wounds  heal  normally  in  places,  whilst  in  other  places 
the  epithelium  grows  in.  The  63^6  may  therefore  not  require  excision 
for  a  prolonged  period.  In  such  cases  the  downgrowths  are  extremely 
irregular  and  tortuous,  so  that  the  canal  is  cut  across  in  various 
directions  in  sections.  Appearances  of  solid  downgrowths,  of  tubes, 
and  of  large  cystic  spaces  are  thus  brought  about.  Such  cystic  spaces 
can  only  be  distinguished  from  true  implantation  cysts  by  means  of 


1 66 


THE    PATHOLOGY   OF   THE    EYE 


serial  sections.  The  wound  edges,  when  clad  with  epithelium, 
cannot  unite  until  this  is  destroyed.  Doubtless  this  takes  place  to  a 
large  extent  in  the  older  cases,  and  the  fistulous  track  which  ultimately 
persists  is  so  tortuous  that  the  aqueous  does  not  escape,  or  only  in 
small  quantities,  the  walls  being  pressed  together  by  the  agency  of  the 
intra-ocular  pressure.  The  condition  is  quite  likely  one  of  the  causes  of 
a  subsequent  secondary  glaucoma,  normal  nitration  being  prevented  by 
the  epithelial  coat ;  in  other  cases  the  track  probably  acts  like  a 
filtering  scar. 

In  one  of  Meller's  cases  the  epithelium  on  the  iris,  etc.,  was  a 
typical  stratified  epithelium,  many  of  the  cells  being  goblet-cells  which 
discharged  their  contents  into  the  anterior  chamber.  The  epithelium 
here  was  probably  derived  from  the  conjunctiva. 

The  condition  here  described  was  first  reported  by  Guaita,  who 
regarded  the  epithelium  as  endothelium,  and  missed  the  true  meaning 
of  the  phenomenon.  It  must  have  been  observed  by  many  others,  and 
I  have  seen  it  several  times,  but  Meller,  working  under  Fuchs,  was  the 
first  to  give  a  comprehensive  account. 

GUAITA. — A.  d'O.,  xiii,  1893.     MELLER. — A.  f.  O.,  Hi,  3,  1901. 


ABRASIONS 

Abrasions  which  involve  only  the  epithelium  are  rapidly  filled  in, 
probably  at  first  by  the  pressure  of  the  neighbouring  cells,  and  later  by 
karyokinesis.  Such  abrasions  heal  without  leaving  any  opacity. 

When  the  injury  extends  deeper  and  involves  Bowman's  membrane, 


FIG.  99. — ABRASION  OF  THE  CORNEA. 

Fuchs,  T.  O.  S.,  xxii.  Facet,  with  destruction  of  Bowman's  membrane,  caused 
by  a  small  corneal  ulcer,  filled  in  with  epithelium.  There  was  no  opacity  or 
alteration  in  level  of  the  surface. 

the  loss  of  tissue  is  replaced  in  the  same  manner  by  epithelium  (Fig. 
99).  Bowman's  membrane  is  never  re-formed,  and  the  thickening  of 
the  epithelium  persists  for  a  prolonged  period.  In  late  stages  it 
resembles  the  normal  corneal  epithelium,  the  basal  cells  being  cylin- 
drical and  lying  directly  upon  the  substantia  propria  or  upon  a  thin 
layer  of  scar  tissue,  the  only  difference  being  an  increase  in  the  number 
of  the  intermediate  layers  of  prickle-cells. 

Even  when  the  loss  of  substance  is  greater  and  involves  the  super- 
ficial lamellae,  the  wound  is  at  first  clothed  with  epithelium  and  then 


THE    CORNEA  167 

filled  in  with  the  same  cells.  Karyokinesis  then  occurs  in  a  zone 
around  the  wound,  exactly  as  in  the  case  of  perforating  wounds.  The 
epithelium  invades  every  crevice  which  is  available,  forming  down- 
growths  and  oblique  or  lateral  processes  into  any  artificial  clefts  and 
also  into  the  interlamellar  lymph-spaces  (cf.  Fig.  131).  These  processes 
are  opposed  by  the  proliferation  of  the  corneal  corpuscles,  which 
gradually  increases,  especially  after  vascularisation  of  the  superficial 
layers  by  vessels  which  grow  in  from  the  periphery  and  bring  pabulum 
for  purposes  of  regeneration.  Ultimately  the  granulation  tissue 
increases  more  rapidly  than  the  epithelium,  which  is  pushed  more  and 
more  towards  the  surface.  The  larger  downgrowths,  however,  often 
persist  indefinitely.  The  granulation  tissue  is  doubtless  partly  derived 


FIG.  100. — CORNEAL  NEBULA,      x  55. 

Note  the  gaps  in  Bowman's  membrane,  filled  in  with  epithelium  lying  upon 
scar  tissue,  which  is  vascularised  in  the  larger  deposit  to  the  left. 

from  the  walls  of  the  larger  new  vessels,  which  possess  a  connective- 
tissue  adventitia,  the  smaller  ones  being  mere  endothelial  tubules.  It  is 
seldom  very  profuse,  owing  to  the  absence  of  vessels  from  the  normal 
tissue.  Finally  the  granulation  tissue  consolidates  into  scar  tissue  in 
the  usual  manner,  the  cells  becoming  spindle-shaped,  and  dwindling 
pari  passu  with  the  development  of  fibrous  tissue.  The  bundles  of 
fibres  are  smaller  than  the  normal  lamellae  and  are  disposed  irregularly, 
so  that  a  permanent  nebula  or  leucoma  results  (Fig.  100).  The  leucocytes 
which  were  present  in  the  granulation  tissue  disappear  for  the  most 
part,  but  groups  of  lymphocytes  often  persist  for  a  very  long  period.  Most 
of  the  vessels  also  disappear,  their  walls  falling  together  and  forming 
part  of  the  scar.  Some  of  the  larger  vessels  often  persist,  and  continue 


168  THE    PATHOLOGY   OF   THE    EYE 

to  carry  blood.  The  epithelium  may  be  even  thinner  than  normal 
over  the  scar,  but  more  frequently  it  remains  thick,  with  an  uneven 
basal  line,  so  that  irregular  papillae  are  formed.  The  larger  down- 
growths  generally  remain,  and  are  often  club-shaped,  being  connected 
with  the  surface  epithelium  by  a  narrow  neck.  The  epithelium  may 
become  epidermoid  by  cornification  of  the  superficial  cells,  but  this  is 
seldom  the  case  except  in  extensive  injuries,  and  is  most  common  in 
anterior  staphylomata  (q.v.). 


ANTERIOR  STAPHYLOMA 

Anterior  staphyloma  is  a  protuberant  cicatrix  arising  from  a  pro- 
lapse of  the  iris  ;  it  may  therefore  be  partial  or  total  (Fig.  101).  It  may 
follow  a  perforating  wound,  but  is  usually  due  to 
the  perforation  of  an  ulcer,  especially  such  as  is 
caused  by  ophthalmia  neonatorum.  The  primary 
protrusion  occurs  at  the  moment  of  prolapse  of  the 
iris.  Cicatrisation  follows,  and  in  the  case  of  small 
prolapse  may  lead  to  flattening  of  the  scar.  In 
other  cases  of  small,  and  in  all  cases  of  large  pro- 
lapse the  contraction  of  the  scar  tissue  is  in- 
sufficient to  bring  this  about,  and  the  soft  cicatrix 
yields  to  the  normal  intra-ocular  tension.  Gener- 
ally the  prolapse  of  the  iris  leads  to  blocking  of  the 
FIG.  101. — ANTERIOR  J.  ,r  . 

STAPHYLOMA.          angle  of  the  anterior  chamber,  the  intra-ocular  ten- 
After  Lawson.   From  si°n  rises,  and  the  cicatrix  yields  still  more,  or,  if 
the  R.  L.  O.  H.  Museum,  it  was  previously  flat,  secondary  protrusion  may  take 

place. 

Partial  staphylomata  are  usually  conical,  rarely  hemispherical ; 
they  usually  extend  to  the  margin  on  one  side.  Total  staphylomata, 
on  the  other  hand,  are  usually  hemispherical,  rarely  conical ;  there  is 
invariably  a  rim  of  cornea  around  the  pseudo-cornea,  even  in  the  worst 
cases,  this  rim  being  well  nourished  by  the  peripheral  blood-vessels  and 
never  necrosing  through  ulceration.  Spherical  staphyloma  is  due  to 
an  extensive  perforation  ;  the  cornea  in  the  vicinity  of  the  opening  is  of 
normal  thickness,  and  the  prolapsed  iris  projects  at  right  angles.  In 
partial  staphyloma  the  perforation  is  less  extensive  and  the  cornea 
tapers  down  towards  the  opening,  but  at  the  same  time  affords  con- 
iderable  support  to  the  iris  (cf.  Fig.  104). 

The  thickness  of  a  staphyloma  varies  very  greatly  in  different  cases, 
and  often  in  different  parts  of  the  same  case.  In  the  latter,  bands 
of  cicatricial  tissue  develop,  whilst  the  intermediate  parts  are  less  sup- 
ported and  project  more;  in  this  manner  a  racemose  staphyloma  is  produced. 
In  the  earliest  stage  there  is  merely  a  prolapsed  iris  covered  with 
exudate,  which  also  fills  the  pupil.  The  iris  is  acutely  inflamed  and 
densely  infiltrated  with  leucocytes.  Granulation  tissue  forms  upon  this 
surface,  often  in  large  masses,  which  may  contain  iris  pigment,  etc.,  and 
remnants  of  the  lens  capsule  and  lens,  if  this  has  been  expelled  from 
the  eye  (Fig.  103).  Epithelium  grows  over  this  granulating  surface, 


THE    CORNEA. 


169 


FIG.  102. — ANTERIOR  STAPHYLOMA  AND  ANTERIOR  CAPSULAR  CATARACT,  x  5. 
From  a  boy  set.  2  ;  the  result  of  ophthalmia  neonatorum.  The  staphyloma  is 
partial,  limited  to  the  lower  part  (on  the  left  of  figure).  Here  the  epithelium  is 
epidermoid  and  horny,  the  cornea  is  replaced  by  fibrous  tissue,  and  the  iris  is  reduced 
to  a  layer  of  pigment  epithelium.  On  the  right  Bowman's  membrane  is  destroyed, 
the  substantia  propria  is  infiltrated  in  the  anterior  layers,  the  posterior  being  intact, 
and  the  iris  is  only  slightly  degenerated.  The  ciliary  body  is  atrophic,  the  processes 
being  stretched  inwards.  The  lens  shows  a  well-marked  anterior  capsular  cataract. 


FIG.  103. — PERFORATED  ULCER  OF  CORNEA,      x  9. 

From  a  child  set.  3  weeks;  ophthalmia  neonatorum.  The  cornea  has  per- 
forated, the  lens  has  been  expelled,  and  the  iris  has  prolapsed.  A  large  mass  of 
granulation  tissue,  partly  covered  by  epithelium,  has  formed  upon  the  ulcer.  The 
lighter  area  in  this,  to  the  right,  is  occupied  by  a  fragment  of  convoluted  lens  capsule. 


170  THE    PATHOLOGY    OF   THE    EYE 

filling  the  crevices  and  developing  at  first  irregularly,  as  in  all  such  con- 
ditions. The  granulation  tissue  gradually  develops  into  scar  tissue  in 
the  usual  manner,  which  need  not  be  recapitulated.  The  iris  stroma 
is  only  apparent  in  the  early  stages ;  it  slowly  atrophies,  and  usually 
becomes  entirely  replaced  by  fibrous  tissue.  The  uveal  pigment  per- 
sists, at  first  as  a  well-defined  layer.  Later  it  becomes  broken  up  ; 
cells  or  clumps  of  pigment  or  isolated  granules  are  found  scattered  in 
the  scar,  but  the  main  part  lines  the  staphyloma.  As  this  stretches 
the  pigment  layer  atrophies  in  parts,  and  the  remainder  becomes 
transformed  into  a  network,  which  varies  greatly  in  different  cases. 

The  thickness  of  the  staphyloma  depends  chiefly  on  the  amount  of 
scar  tissue,  though  the  epithelium  also  differs  in  this  respect.  It  may 
be  as  thin  as  paper,  and  is  not  often  thicker  than  the  normal  cornea. 
The  epithelium  may  grow  directly  on  the  prolapsed  iris,  the  granula- 


FIG.  104. — ADHERENT  LEUCOMA.      x   25. 

From  a  man  aet.  61  ;  following  perforating  ulcer.  The  central  part  consists 
of  degenerated  iris,  containing  the  sphincter,  covered  by  epithelium  ;  the  thicker  part 
to  the  right  of  the  centre  has  a  few  corneal  lamellae  interposed.  At  the  extreme 
right  and  left  the  cornea  is  of  average  thickness,  but  is  infiltrated  and  vascularised 
anteriorly.  There  is  an  anterior  capsular  cataract. 

tion  tissue  being  reduced  to  a  minimum  (Fig.  104).  Often  Descemet's 
membrane  is  prolapsed  and  convoluted  (Fig.  105),  and  I  have  seen  the 
epithelium  growing  upon  this,  filling  in  all  the  convolutions. 

The  epithelium  is  usually  very  thick,  often  showing  downgrowths  or 
forming  true  papillae.  There  are  sometimes  epithelial  nests,  and  prickle- 
cells  are  generally  developed  in  the  middle  layers.  It  frequently  be- 
comes typically  epidermoid  ;  keratohyalin  granules  form  in  the  upper 
layers,  staining  deeply  \\ith  hsematoxylin  or  by  Gram's  method,  whilst 
the  surface  layers  lose  their  nuclei  and  become  horny  (Fig.  106).  Various 
degenerative  changes  occur  in  the  epithelium,  especially  over  calcareous 
deposits  (Fuchs)  (v.  infra),  and  atheromatous  ulcers  occur  in  these 
eyes  (q.  v.).  Spaces  form  in  the  epithelium,  separated  by  thin  walls  of 


THE    CORNEA 


171 


FIG.  105. — ANTERIOR  STAPHYLOMA.      x  60. 

From  a  specimen  by  Verhoeff.  This  resembles  the  edge  of  the  bay  in  Fig. 
104.  On  the  right  is  the  cornea,  around  the  edge  of  which  the  ruptured  Descemet's 
membrane  is  much  folded.  Below  this  the  iris  is  of  normal  thickness  ;  anteriorly 
it  is  spread  out  over  the  edge  of  the  cornea,  and  more  to  the  left  it  is  thin  and 
covered  directly  by  epithelium. 


FlG.    IO6. CORNIFICATION  OF  EPITHELIUM  OF  ANTERIOR  STAPHYLOMA.        X    55. 

From  an  anterior  staphyloma  of  twelve  years'  duration.  The  epithelium  is 
typically  epidermoid,  with  well-marked  true  papillae.  The  superficial  cells  are 
corneous,  devoid  of  nuclei ;  the  layer  below  this  contains  granules  of  keratohyalin. 
Note  the  blood-vessels  in  the  pseudo-cornea. 


172 


THE   PATHOLOGY   OF  THE   EYE 


shrunken  cells ;  they  are  formed  between  the  cells  and  not  by  vacuola- 
tion,  and  are  often  covered  by  a  single  layer  of  epithelium  only. 

The  scar  tissue  consists  of  very  dense  fibrous  tissue,  with  few  cells 
and  few  vessels.  Pigment  is  found  here  and  there,  and  calcareous 
deposits  often  occur.  Sometimes  the  fibrous  tissue  shows  hyaline 
degeneration,  and  masses  of  hyaline  or  granular  material  may  replace 
the  superficial  layers.  The  hyaline  deposits  may  occur  as  granules, 
globules  and  concretions,  or  great  masses  and  whorls  of  hyaline  fibrous 
tissue  may  be  found  (v.  infra,  "  Degenerations  ").  The  thickness  varies 
much  in  different  parts,  owing  to  the  bands  which  project  upon  the 
posterior  surface.  At  the  extreme  periphery  remnants  of  Bowman's 
and  Descemet's  membranes  may  be  found. 

Sachsalber  found  large  numbers  of  elastic-tissue  fibres  in  the  sclera, 


FIG.  107. — ANTERIOR  STAPHYLOMA. 

Photograph  by  Lister.  From  a  child  set.  2  years  8  months.  There  is  an  area 
of  purulent  infiltration,  stained  dark  in  the  figure.  The  posterior  chamber  is  full 
of  fibrin  and  leucocytes. 

episclera,  peripheral  part  of  the  cornea,  and  to  a  less  extent  in  the 
conjunctiva  in  cases  of  anterior  staphyloma.  These  form  fine,  very 
wavy  fibres,  which  stain  deeply  with  eosin ;  they  increase  in  length  and 
breadth,  become  spiral  and  irregular  in  thickness,  and  finally  break  up 
into  hyaline  granules  and  clumps.  The  condition  is  allied  to  that  found 
in  pinguecula. 

In  some  of  the  hyaline  deposits  in  anterior  staphyloma  Beselin 
obtained  a  typical  amyloid  reaction  with  iodine  and  iodine  violet, 
whereas  with  gentian  violet  and  methyl  violet  the  reaction  was  incon- 
clusive. There  is  therefore  the  same  uncertainty  about  the  chemical 
nature  of  the  deposits  in  this  situation  as  in  the  conjunctiva  and  else- 
where (v.  p.  96). 


THE    CORNEA  173 

Schiele,  using  the  iodine  test,  found  glycogen  present  in  the 
epithelium,  in  newly  formed  connective  tissue,  and  in  the  corneal 
corpuscles. 

The  anterior  chamber  is  obliterated,  whilst  the  posterior  chamber 
is  enormously  enlarged.  The  ciliary  body  is  usually  atrophic,  owing  to 
the  rise  of  tension,  and  the  ciliary  processes  are  dragged  inwards  and 
elongated  by  the  fibres  of  the  zonule  of  Zinn.  The  lens  is  often  absent, 
having  been  expelled  when  the  perforation  occurred.  In  other  cases  it 
is  cataractous  and  shrunken ;  frequently  it  shows  an  anterior  capsular 
or  a  pyramidal  cataract.  It  is  often  subluxated.  The  other  parts  of 
the  eye  show  changes  dependent  chiefly  upon  the  secondary  glaucoma. 

The  fluid  contained  in  the  posterior  chamber  differs  from  normal 
aqueous.  It  is  generally  yellow,  rich  in  proteids,  and  capable  of 
coagulating.  It  often  contains  cholesterin  crystals,  blood,  etc. 

SACHSALBER. — B.  z.  A.,  xlviii,  1901.  BESELIN. — A.  f.  A.,  xvi,  1886.  SCHIELE. — 
A.  f.  A.,  xix,  1889. 


FIG.  108. — KERATECTASIA.      x  23. 

From  a  man  set.  45  ;  iridectomy  at  age  of  twelve.  A.  c.  very  deep ;  angles 
blocked.  Cornea  thickened  in  centre  by  hyaline  degeneration  (v.  infra). 
Stretching  of  the  cornea  has  produced  rupture  of  Descemet's  membrane,  which  is 
coiled  forwards  in  a  spiral  at  the  inner  end.  A  new  hyaline  membrane  has  been 
formed  on  the  back  of  the  cornea.  These  membranes  show  definite  lamellation 
in  places. 

KERATECTASIA 

Keratectasia  is  a  protrusion  of  the  cornea  which  sometimes  follows 
inflammatory  processes  in  it  without  perforation.  It  consists  of  corneal 
tissue,  and  the  iris  plays  no  part  in  its  formation. 

The  cornea  is  softened  by  the  inflammation  or  partially  destroyed 


174  THE    PATHOLOGY   OF  THE   EYE 

by  ulceration,  so  that  it  is  unable  any  longer  to  withstand  the  normal 
intra-ocular  pressure.  If  only  Descemet's  membrane  persists,  a  keratocele 
is  produced,  and  this  may  cicatrise  in  the  form  of  keratectasia.  It  then 
forms  a  transparent  vesicle  projecting  above  the  surface  and  surrounded 
by  a  ring  of  opaque  cicatricial  tissue.  After  ulceration  only  a  partial 
keratectasia  is  usually  produced.  After  parenchymatous  keratitis,  etc., 
the  whole  cornea  protrudes. 

The  cicatrix  is  usually  thinner  than  the  normal  cornea.  It  consists 
of  a  thick  epithelial  layer  lying  upon  scar  tissue,  Bowman's  membrane 
having  been  destroyed,  at  any  rate  in  such  cases  as  may  come  under 
microscopical  observation.  The  fibrous  tissue  may  undergo  any  of  the 
degenerative  changes  which  occur  in  anterior  staphyloma,  etc.  Fig. 
108  shows  hyaline  degeneration  in  marked  degree.  In  this  case  the 
cornea  was  thickened,  probably  owing  to  the  swelling  of  the  degene- 
rated fibres.  Descemet's  membrane  and  the  endothelium  persist 
unchanged,  though  pushed  forwards  and  often  wavy.  When  the 
protrusion  is  excessive  Descemet's  membrane  may  rupture,  as  in 
buphthalmia  (Fig.  108),  and,  indeed,  the  conditions  may  so  nearly 
resemble  buphthalmia  that  an  accurate  diagnosis  is  difficult. 

CONICAL  CORNEA 

Conical  cornea,  or  keratoconus,  is  a  form  of  keratectasia.  It  has  rarely 
been  examined  microscopically.  Bowman  (1859)  removed  an  eye  with 
this  disease,  and  it  was  examined  by  Hulke.  The  portion  trephined  by 
the  same  surgeon  in  1875  from  another  case  was  reported  on  by  Brailey. 
Hulke  found  the  central  part,  which  was  nebulous,  much  thinner  than 
the  periphery,  and  this  is  the  experience  of  all  operators.  There  was 
gradual  thinning  towards  the  apex.  Bowman's  membrane  was  intact, 
but  thinned  and  wrinkled  over  the  apex ;  Descemet's  membrane  was 
unchanged.  Brailey  found  spaces  in  the  superficial  layers  of  epithelium. 
The  pathology  of  the  disease  has  been  discussed  by  many  observers, 
with  widely  divergent  results.  As  these  are  purely  theoretical,  they 
merely  demand  enumeration :  (i)  Increased  intra-ocular  pressure  (v. 
Graefe,  de  Wecker  and  Landolt)  ;  (2)  malnutrition  (Lawson,  Nettle- 
ship,  Swanzy,  Berry,  etc.)  ;  (3)  diminution  of  the  resistance  of  the 
cornea  (Soelberg  Wells,  de  Wecker  and  Masselon) ;  (4)  inherent 
weakness,  and  deficient  firmness  and  thickness  of  the  cornea  (Macna- 
mara,  Williams) ;  (5)  defective  embryological  development  and  growth 
of  the  centre  of  the  cornea  (Tweedy) ;  (6)  chronic  disease  of  Descemet's 
membrane  and  the  endothelium  (Panas,  Elschnig) ;  (7)  relatively 
greater  extra-ocular  than  intra-ocular  pressure  (Gullstrand),  etc. 

BOWMAN. — R.  L.  O.  H.  Rep.,  ii,  1859.  BRAILEY. — R.  L.  O.  H.  Rep.,  viii,  2,  1875. 
TWEEDY. — T.  O.  S.,  xii,  1892.  PANAS. — A.  d'O.,  v,  1885.  ELSCHNIG. — K.  M.  f.  A.,  xxxii, 
1894.  GULLSTRAND. — A.  f.  A.,  xxvi  (Literaturbericht),  1892. 


(EDEMA 

(Edema  of  the  cornea  was  first  described  and  investigated  by  Leber 
and  Fuchs,  though  bullous  keratitis  had  already  been  examined  micro- 
scopically by  v.  Graefe.  The  condition  is  found  most  frequently  in 
cases  of  increased  tension,  though  it  also  occurs  in  panophthalmitis  and 
many  other  affections.  There  is  usually  a  uniform  haze  of  the  cornea, 
with  marked  dulness  of  the  surface,  which,  when  magnified,  shows 
uneven  epithelium.  In  more  advanced  cases  minute  vesicles  are 
formed  (vesicular  keratitis),  and  these,  especially  in  cases  of  deep 


FIG.  109. — (EDEMA  AND  ATROPHY  OF  EPITHELIUM,      x  200. 
Glaucoma  two  and  a  quarter  years  after  extraction  of  f.  b.  from  vitreous  with 
Haab's  magnet.     The  basal  epithelial  cells  are  elongated,  vacuolated  and  separated 
by  droplets  of  fluid.     To  the  left  they  have  disappeared,  only  the  flattened  super- 
ficial cells  remaining. 

parenchymatous  inflammation,  may  increase  in  size  and  form  distinct 
blebs  (bullous  keratitis). 

Microscopically  changes  are  found  in  all  the  layers  of  the  cornea. 

Epithelium. — In  the  epithelium,  small  drops  of  liquid  are  found  at 
first  between  the  basement  cells,  but  later  the  channels  between  the 
prickle-cells  are  broadened,  and  ultimately  the  oedema  extends  to  the 
superficial  cells,  which  are  loosened  and  often  cast  off  (Fig.  no).  In 
hardened  specimens  the  fluid  is  coagulated  in  places,  forming  small 
granular  clots  between  the  cells.  The  fluid  between  the  basal  cells 
forms  small  droplets,  which  may  be  arranged  in  rows,  like  the  beads  of 
a  rosary.  The  cells  may  be  lifted  up  from  Bowman's  membrane  by  the 
fluid.  In  the  middle  layers  the  prickle-cells  are  forced  apart,  so  that 
the  tooth-like  processes  are  very  clearly  seen,  though  they  do  not  now 


176  THE    PATHOLOGY   OF   THE    EYE 

interlock  as  under  normal  conditions.  The  superficial  cells  are  usually 
last  and  least  affected.  A  few  leucocytes  are  often  seen  between  the 
cells. 

The  cells  themselves  also  become  vacuolated.  The  basal  cells  are 
often  elongated,  the  basal  parts  containing  fluid  which  does  not  stain, 
whilst  the  nuclei  occupy  the  distal  ends  (Figs.  109,  116).  If  the 
swelling  is  great  some  of  the  cells  burst  and  leave  small  depressions, 
which,  together  with  the  swollen  and  projecting  cells,  render  the  surface 
of  the  cornea  uneven  and  lustreless  (Fig.  in).  This  change  is  the 
usual  cause  of  the  stippled  appearance  in  cases  of  glaucoma,  irido- 
cyclitis,  interstitial  keratitis,  etc. 

Sometimes  the  redema  affects  most  the  middle  or  deepest  layer  of 
cells,  or  the  epithelium  may,  by  uniform  swelling,  be  changed  in  some 
places  into  a  nearly  homogeneous  mass,  which  soon  falls  off  entirely. 
In  other  cases  successive  layers  of  cells  are  alternately  swollen,  the 
swollen  layers  being  recognisable  by  the  greater  diameter  and  lighter 
tinge  of  the  cells  (Fig.  112).  This  proves  successive  changes  in  the 
pathological  process  which  causes  the  swelling.  It  is  probable  that  the 
changes  in  the  epithelium  described,  viz.,  oedema  and  swelling,  are 
often  very  transient,  the  liquid  becoming  absorbed  as  quickly  as  it  is 
produced  (Fuchs). 

The  liquid  effused  in  and  between  the  cells  diminishes  their 
coherence,  so  that  the  superficial  cells  fall  off.  This  desquamation  is 
never  entirely  absent  in  cases  of  acute  corneal  disease,  its  intensity 
depending  on  the  degree  and  on  the  special  character  of  the  in- 
flammation, being  found  par  excellence  in  neuro-paralytic  keratitis.  In 
the  slightest  degrees  single  cells  only  are  exfoliated;  in  severer  cases 
whole  layers  of  cells  are  thrown  off  (Fig.  113).  The  basal  cells  are  then 
often  small  and  cubical,  staining  deeply ;  they  are  young  cells  which 
have  to  divide  so  rapidly  to  replace  the  loss  that  they  have  not  time  to 
reach  full  maturity.  After  the  elimination  of  the  superficial  cells  the 
surface  is  usually  uneven  (Fig.  114),  and  this  also  may  be  a  cause  of  the 
stippled  appearance  seen  clinically.  Rarely  the  surface  remains  smooth. 
If  the  desquamation  increases  it  may  leave  behind  only  the  basement 
layer  of  cells,  which  are  then  either  short  and  cubical  or  long  and  thin 
(Fig.  115).  In  the  latter  case  they  are  often  set  obliquely  on  Bowman's 
membrane,  owing  to  the  pressure  of  the  lids.  Desquamation  may  go  so 
far  as  to  lead  to  entire  loss  of  the  epithelium. 

The  effusion  between  and  vacuolation  of  the  deeper  cells  may  lead 
to  the  formation  of  microscopic  vesicles.  In  the  same  manner  larger 
cystic  spaces  arise,  between  which  the  epithelial  cells  are  compressed,  so 
that  they  become  elongated  and  spindle-shaped,  often  losing  their 
nuclei  and  appearing  as  fibrous  walls  to  the  cysts  (Klebs). 

Vesicular  and  bullous  keratitis  is  due  to  the  formation  of  vesicles 
and  blebs  in  the  epithelium  (Fig.  116).  It  often  occurs  after  in- 
flammation, but  without  direct  relation  to  the  actual  infiltration  (Bock). 
The  intact  vesicles  are  rarely  seen  microscopically.  The  walls  consist 
of  spindle-shaped  epithelial  cells,  often  projecting  into  the  lumen, 
which  may  contain  a  few  leucocytes  or  red  corpuscles  and  granular 
debris.  The  larger  blebs  of  bullous  keratitis  have  been  investigated  by 


THE    CORNEA 


177 


FIG.  no. — (EDEMA  OF  THE  CORNEA. 
Fuchs,  after  Greeff,  T.  O.  S.,  xxii.  Swollen  vacuo- 
lated  cells  on  the  surface ;  separation  of  the  prickle- 
cells  with  fluid ;  drops  of  fluid  between  and  beneath  the 
basal  cells  ;  dilatation  of  the  nerve-canals  in  Bowman's 
membrane ;  coagulated  exudation  between  Bowman's 
membrane  and  the  superficial  lamellae ;  separation  of 
the  lamellae  by  fluid. 


FlG.    112.— (EDEMA    OF    THE    CORNEA. 

Fuchs,  T.  O.  S.,  xxii.  CEdema  of 
alternate  layers  of  the  epithelium.  The 
swollen  cells  stain  less  deeply. 


FlG.   113. OEDEMA    OF    THE    CORNEA. 

Fuchs,  T.  O.  S.,  xxii.  CEdema  of  the 
epithelium  leads  to  loosening  of  the  super- 
ficial layers,  resulting  in  desquamation. 
From  a  case  of  acute  gonorrhreal 
ophthalmia,  in  which  the  cornea  looked 
apparently  normal.  Note  that  the  basal 
cells  are  small  and  square,  due  to  rapid 
regeneration ;  this  is  further  shown  by 
their  staining  deeply. 


FIG.  in. — (EDEMA  OF  THE  CORNEA. 
Fuchs,  T.  O.  S.,  xxii.     Vacuolation  and  rupture  of 
the  superficial  epithelial  cells,  causing  unevenness  and 
stippling  of  the  surface  of  the  cornea. 


FIG.  114. — DESQUAMATION  OF  EPITHELIUM. 
Fuchs,  T.  O.  S.,  xxii.      Desquamation  of  the  super- 
ficial cells,  leaving  the  surface  uneven,  causing  a  stippled 
appearance. 


FIG*.  115. — DESQUAMATION  OF  EPI- 
THELIUM. 

Fuchs,  T.  O.  S.,  xxii.  All  but  the 
basal  cells  have  been  cast  off.  These  are 
elongated,  and  are  oblique,  owing  to  the 
pressure  of  the  lids.  Note  the  erosion  of 
the  anterior  surface  of  Bowman's  mem- 
brane, the  space  being  overfilled  with  scar 
tissue.  This  resembles  the  deposits  de- 
scribed by  Baas  in  old  phlyctenules,  but 
in  these  the  erosion  was  from  behind  (v. 
p.  190). 


I  2 


i78 


THE    PATHOLOGY   OF   THE    EYE 


v.  Graefe,  Fuchs,  Schweigger,  and  others.  They  are  much  more  resistant 
than  the  vesicles,  and  Fuchs  attributes  it  to  the  formation  of  a  new  fibrous 
membrane  in  the  anterior  wall.  This  consists  of  long  connective-tissue 
fibres  with  few  nuclei ;  in  one  case  it  contained  no  blood-vessels,  in 
another  it  was  richly  vascularised.  The  quite  normal  epithelium  lay 
upon  this  membrane  ;  the  posterior  wall  of  the  bleb  was  formed  by 
Bowman's  membrane.  Hess,  however,  never  found  any  traces  of 
Bowman's  membrane  in  the  wall.  Treacher  Collins  describes  the 
development  of  dense  fibrous  tissue  between  the  epithelium  and 
Bowman's  membrane,  the  latter  being  broken  by  the  extension  through 
it  from  behind  forwards  of  considerable  collections  of  fibrous  tissue. 
He  considers  that  this  develops  in  the  distended  spaces. 


FIG.  116. — (EDEMA  OF  THE  CORNEA,      x  60. 

From  a  glaucomatous  eye.  The  epithelium  is  cedematous  ;  on  the  left  the  cells 
of  the  central  layers  are  vacuolated;  on  the  right  the  basal  cells  are  elongated  and 
vacuolated.  A  large  vesicle  is  seen,  the  epithelium  being  raised  by  the  accumulated 
fluid.  Bowman's  membrane  has  been  absorbed  as  far  as  near  the  extreme  right  of 
the  figure,  which  is  towards  the  centre  of  the  cornea.  The  lamellae  are  separated 
by  fluid  except  at  the  posterior  part. 

The  vesicles  in  herpes  cornea  (febrilis  and  zoster)  are  probably 
identical  microscopically  with  those  of  vesicular  keratitis.  The  occur- 
rence of  vesicles  in  herpes  has  led  some  authors  to  suppose  that  local 
nervous  irritation  is  a  factor  in  the  production  of  ordinary  vesicular  and 
bullous  keratitis  (Birnbacher  and  Czermak,  Panas). 

Substantia  propria. — (Edema  of  the  cornea  manifests  itself  in  the 
substantia  propria  by  widening  the  interlamellar  lymph-spaces  (Figs, 
no,  116).  The  lamellae  themselves  contain  more  fluid,  and  are  swollen. 
They  are  separated  by  clefts,  which  are  largest  immediately  below 
Bowman's  membrane,  and  diminish  in  size  from  before  backwards. 
The  spaces  contain  clear  fluid  or  granular  coagula  (Fig.  no),  with  a 
few  leucocytes,  and  are  often  spanned  by  fine  fibres.  The  corneal 


THE    CORNEA  179 

corpuscles  are  flattened  against  the  lamellae,  which  are  often  wavy. 
There  is  usually  a  space  between  Bowman's  membrane  and  the 
lamellae.  The  perineural  lymph-spaces  are  also  dilated,  and  are  most 
clearly  seen  where  they  traverse  Bowman's  membrane. 

Descemefs  membrane  and  endothelium. — Descemet's  membrane  is 
unchanged,  but  the  endothelium  is  probably  often  affected.  Leber  has 
shown  that  fluid  cannot  enter  the  cornea  from  the  anterior  chamber  as 
long  as  the  endothelium  is  intact.  Fuchs  considers  that  the  endo- 
thelium is  often  altered  pathologically  in  these  cases,  resulting  in 
changes  in  form  of  the  cells  and  dilatation  of  the  intercellular  spaces,  so 
that  fluid  is  able  to  reach  the  cornea.  It  is  probable  from  E.  v. 
Hippel's  experiments  with  fluorescei'n  that  these  changes  are  more 
frequent  than  has  hitherto  been  suspected  (see  "  Interstitial  Keratitis  "). 
At  the  same  time  it  cannot  be  doubted  that  this  is  only  a  subsidiary 
factor  in  oedema  of  the  cornea,  and  that  the  condition  depends  essentially 
upon  anomalies  in  the  lymph  circulation  in  the  cornea  itself,  and  this  is 
related  most  intimately  with  the  peripheral  blood-vessels  in  the  limbus 
(Leber,  Birnbacher  and  Czermak). 

v.  GRAEFE. — A.  f.  O.,  ii,  i,  1853.  SCHWEIGGER. — Lehrbuch  der  Augenheilkunde, 
1873.  LEBER.— A.  f.  O.,  xxiv,  i,  1878.  *FucHS—  A.  f.  O.,  xxvii,  3,  1881  ;  T.  O.  S.,  xxii, 
1902.  BOCK. — K.  M.  f.  A.,  xxiv,  1886.  BIRNBACHER  AND  CZERMAK. — A.  f.  O.,  xxxiii,  2, 
1887.  KLEBS. — Ziegler's  Beitrage,  xvii,  1895.  HESS. — A.  f.  O.,  xxxix,  i,  1893.  TREACHER 
COLLINS. — Lancet,  1900.  PANAS. — Le9ons  de  Clinique  opht.,  Paris,  1899.  STOLTING. — 

K.  M.  f.  A.,  XXxix,   1901.       DE   SCHWEINITZ  AND  SHUMWAY. A.  of  O.,  XXXli,   1903. 


STRIATE     OPACITY 

Striate  opacity,  or  so-called  Striate  Keratitis  (Streifenkeratitis, 
Faltentriibung),  of  the  cornea  occurs  under  various  conditions. 

The  lines  appear  sometimes  as  more  or  less  straight  and  parallel 
bars  of  light  grey  opacity  in  the  substance  of  the  cornea ;  sometimes 
they  are  unbranched,  sometimes  they  are,  or  appear  to  be,  branched, 
or  crossed  by  other  bars  running  at  different  angles  ;  in  some  cases 
the  points  of  crossing  of  the  several  lines  are  increased  in  size  by  the 
formation  of  a  nodule  of  opacity  where  the  two  lines  come  into  contact. 
The  bars,  as  a  rule,  appear  to  be  quite  solid  and  granular,  and  may 
reach  a  width  of  about  0*5  mm. ;  instead  of  being  solid,  they  are 
occasionally  seen  to  have  a  double  contour, — that  is  to  say,  each  line  is 
made  up  of  two  distinct  lines  with  a  comparatively  clear  space  between 
them ;  when  this  arrangement  is  present,  the  appearance  is  very 
strongly  suggestive  of  a  tubular  formation  in  the  substance  of  the  cornea 
(Holmes  Spicer). 

Many  of  the  cases  are  traumatic,  and  present  a  series  of  fine  grey 
lines  running  from  the  edge  of  the  wound  towards  the  centre  of  the 
cornea.  The  traumatic  variety  that  has  excited  the  greatest  amount 
of  interest  and  provoked  the  greatest  amount  of  discussion  is  that 
which  is  one  of  the  commonest  sequels  of  cataract  extraction.  The 
duration  of  the  phenomenon  varies  between  a  few  hours  and  several 
weeks. 


i8o  THE    PATHOLOGY   OF   THE    EYE 

Becker  described  the  appearances  seen  in  the  case  of  a  girl  who 
had  had  a  diabetic  cataract  removed  by  operation  and  died  two  days 
after  ;  well-marked  striate  opacity  was  present  before  death.  Micro- 
scopic examination  showed  a  marked  widening  of  the  tissue  spaces  in 
the  cornea,  especially  in  its  deeper  layers  ;  a  few  lymphoid  cells  were 
present,  but  there  was  no  great  cellular  exudation. 

v.  Recklinghausen  described  the  examination  of  another  case  in 
which  there  was  widening  of  the  lymph-spaces  of  the  cornea,  especially 
in  the  deeper  layers. 

Nuel  next  suggested,  from  clinical  observation  and  from  the 
examination  of  a  cornea  post  mortem,  the  following  explanation  : — The 
whole  cornea  is  creased  or  folded ;  on  the  summit  of  the  folds  the 
endothelium  suffers  a  solution  of  continuity,  and  a  non-inflammatory 
infiltration  of  the  cornea  ensues.  He  considered  that  the  folds  might 
be  produced  by  pressure  of  a  bandage. 

This  was  the  starting-point  of  another  theory,  first  put  forward  by 
Hess,  that  the  folds  are  not  due  to  a  pressure  bandage,  as  they  occur 
when  the  eye  has  not  been  bandaged.  From  the  examination  of  an 
excised  eye  affected  with  striate  opacity,  and  from  a  series  of  experi- 
ments on  rabbits'  eyes,  he  concluded  that  a  widening  of  the  corneal 
spaces  was  not  present,  or,  if  so,  in  the  superficial  layers  only,  and  that 
the  lines  were  due  to  a  folding  of  the  posterior  layers  of  the  cornea, 
including  Descemet's  membrane.  This  folding  was  due  to  the 
alteration  in  tension  of  Descemet's  membrane,  consequent  upon  the 
section. 

Since  then  Schirmer  has  confirmed  this  view  by  a  series  of  experi- 
ments on  rabbits.  He  is  of  opinion  that  the  pathological  appearances 
shown  in  Becker's  sections  do  not  explain  the  clinical  phenomena. 
According  to  Becker,  there  are  large  numbers  of  small  lymph-spaces 
running  in  various  directions  through  the  corneal  parenchyma,  and 
crossing  one  another,  whereas  clinically  we  see  individual  streaks 
several  millimetres  long  by  about  0*5  mm.  broad,  which  commonly 
do  not  cross,  but  run  at  right  angles  to  the  direction  of  the  wound  in  a 
more  or  less  parallel  direction.  Schirmer  next  deals  with  the  striate 
opacities  which  appear  in  keratitis  with  hypopyon,  and  he  thinks  these 
are  caused  by  folds  in  Descemet's  membrane,  for  the  following  reasons: — 
By  transmitted  light  they  appear,  not  as  opaque  lines,  but  as  clear, 
bright  streaks  ;  they  therefore  depend  on  a  difference  in  light  reflection. 
They  occur  at  one  level  only,  that  of  Descemet's  membrane  ;  they 
radiate  from  the  edge  of  the  ulcer,  an  arrangement  which  does  not 
exist  in  any  of  the  natural  spaces  of  the  corneal  parenchyma.  They 
are,  therefore,  clinically  identical  with  the  striae  which  appear  after 
cataract  extraction. 

Leber  draws  a  strong  distinction  between  the  actual  stripes  and  the 
diffuse  opacity  which  often  occurs  between  them.  This,  according  to  both 
Leber  and  Schirmer,  is  due  to  absorption  of  fluid,  permitted  by  lesions 
of  the  endothelium  of  Descemet's  membrane.  It  is  found  especially 
after  difficult  extractions,  with  considerable  bruising  of  the  cornea  and 
the  edges  of  the  wound. 

Holmes  Spicer  has  recorded  a  series  of  cases  with  marked  striate 


THE    CORNEA 


181 


opacity.  He  draws  attention  to  the  frequency  of  inflammation  of  the 
uveal  tract,  shown  generally  by  iritis  or  by  keratitis  punctata.  He  is 
inclined  to  regard  some  cases  as  due  to  oedema  of  the  posterior  layers 
of  the  cornea,  the  arrangement  of  the  vertical  lines  being  possibly 
aided  by  the  pressure  of  the  lids. 

Another  factor  in  some  cases  is  probably  the  contraction  of 
cicatricial  tissue,  leading  to  folding  of  Descemet's  membrane  (Schirmer); 
but  this  will  not  account  for  the  early  onset  in  cases  of  cataract 
extraction. 

I  have  observed  a  case  of  well-marked  striate  opacity,  due  to 
differences  of  refrangibility  in  an  otherwise  clear  cornea,  in  a  case  of 


FIG.  117. —  STRIATE  OPACITY  OF  THE  CORNEA,      x   7. 

From  a  case  of  phthisis  bulbi  (see  text).  Note  the  wrinkling  of  Descemet's 
membrane  and  of  the  corneal  lamellse ;  Bowman's  membrane  is  intact  and  flat. 
There  is  some  oedema  of  the  substantia  propria.  Note  the  retraction  of  the  iris 
and  deepening  of  the  anterior  chamber. 

phthisis  bulbi,  in  which  the  corneal  curvature  was  markedly  increased 
by  the  shrinking  of  the  posterior  part  of  the  eye,  Descemet's  membrane 
being  thrown  into  folds.  The  appearance  clinically  resembled  cracked 
ice  (Fig.  117). 

A  totally  different  type  of  striate  opacity  occurs  in  cases  of  detached 
retina  which  have  been  treated  by  firm  bandaging.  The  stripes  are 
not  parallel,  but  cross  each  other  in  all  directions,  like  crumpled  paper. 
These  are  said  to  be  due  to  folding  of  the  deeper  layers  (Nuel, 
Deutschmann,  Fuchs). 

Allied  to  striate  keratitis  is  a  condition  found  under  the  same 
conditions  after  cataract  extraction.  The  opacity  is  uniform,  or  only 
divided  into  a  number  of  square  areas  by  fine  dark  lines.  This  opacity 


182 


THE    PATHOLOGY    OF   THE    EYE 


cannot  be  caused  by  folding  alone,  but  is  due  to  imbibition.  The 
microscope  shows  the  lamellae  of  the  cornea  within  the  limits  of  the 
swelling  to  be  separated  by  effused  liquid  ;  sometimes  they  exhibit  a 
very  fine  folding,  and  have  grown  thicker  by  it  (Fuchs). 

Schirmer  has  described  a  similar  condition  after  injury,  where,  in 
the  highly  cedematous  cornea,  there  is  a  central  opacity  divided  up 
into  irregular  areas  by  straight  dark  lines,  crossing  each  other  at 
various  angles.  He  calls  it  "  thread-like  "  (fadenformig)  opacity,  and 
considers  it  an  advanced  form  of  striate  opacity. 

The  radial  striae  described  by  Schirmer  in  hypopyon  ulcer  had 
already  been  pointed  out  in  the  works  of  Saemisch,  v.  Michel,  Fuchs, 
de  Wecker,  and  Schmidt-Rimpler.  They  are  2 — 6  mm.  long,  and 
i — i  mm.  broad  near  the  ulcer ;  they  never  branch,  and  are  usually 
straight,  rarely  slightly  wavy.  As  already  mentioned,  they  depend 
upon  differences  of  refraction,  and  are  due  to  crumpling  of  Descemet's 
membrane  and  the  adjacent  lamellae.  They  must  therefore  be  care- 


FIG.  118. — WRINKLING  OF  BOWMAN'S  MEMBRANE,  x  55. 
Bowman's  membrane  is  intact,  but  wrinkled.  The  depressions  are  filled  in 
with  epithelium,  the  surface  of  the  epithelium  being  level.  The  condition,  which  is 
not  very  common,  is  found  in  some  shrunken  globes,  and  is  probably  due  to 
irregular  stress  and  strain,  caused  by  the  contraction  of  the  posterior  part  of  the 
globe. 

fully  distinguished  from  the  true  radiating  opacities  which  branch,  and 
which  are  due  to  infiltration  of  the  lymph-spaces  (v.  p.  187). 

Geometrically  arranged  systems  of  opaque  lines  have  been  described 
by  Friedenberg,  Dimmer,  and  others,  as  an  unusual  sequel  of  inter- 
stitial keratitis.  They  are  also  probably  due  to  folding  of  Descemet's 
membrane,  though  Friedenberg  ascribes  them  to  deposits  of  fat  in 
the  lymph-spaces.  Raehlmann  described  them  in  various  types  of 
secondary  parenchymatous  keratitis. 

Schirmer  has  also  described  striate  opacities  in  which  Bowman's 
membrane  is  folded,  and  I  have  also  observed  these.  Schirmer's  case 
was  a  shrunken  globe,  in  which  the  cornea  was  much  diminished  in 
size,  hazy,  and  traversed  by  fan-like  stripes,  diverging  above,  where 
they  did  not  reach  the  corneal  margin,  and  ending  below  in  a  horizontal, 
slightly  bent,  grey  line.  In  horizontal  sections,  there  were  six  waves 
in  the  epithelial  surface,  below  which  were  sharp  triangular  depressions 
in  Bowman's  membrane,  which  was  intact  (cf.  Fig.  118). 


THE    CORNEA  183 

BECKER. — Atlas  der  path.  Topog.  des  Auges,  plate  xxx,  1878.     v.  RECKLINGHAUSEN. — 
B.  d.  o.  G.,   1887.     NUEL. — Bull,  et  Memoires  de  la  Soc.  fran9.  d'Opht.,   1892.     HESS. — 

A.  f.  O.,  xxxviii,  4,  1892;  A.  f.  A.,  xxxiii,  1896.     SCHIRMER. — A.  f.  O.,  xlii,  3, 1896.     LEBER. 
— B.  d.  o.  G.,  1887.     *HOLMES  SPICER. — R.  L.  O.  H.  Rep.,  xiv,  1896.     DEUTSCHMANN. — 

B.  z.  A.,  i,  1890.     FUCHS. — T.  O.  S.,  xxii,  1902.      FRIEDENBERG. — New  York  Eye  and  Ear 
Inf.  Rep.,  1895.     DIMMER. — Z.  f.  A.,  v,  1901.     RAEHLMAXN. — K.  M.  f.  A.,  xv,  1877. 


FILAMENTARY  KERATITIS 

Filamentary  keratitis  (Fadchenkeratitis)  sometimes  occurs  after 
abrasions,  wounds,  and  rarely  without  any  apparent  cause.  Fine  fila- 
ments appear  upon  the  cornea,  2 — 4  mm.  long,  firmly  attached  at  one 
end,  the  free  end  having  a  knob.  In  idiopathic  cases  they  are  usually 
preceded  by  vesicles. 


FIG.  119. — FILAMENTARY  KERATITIS. 

After  Hess,  A.  f.  O.,  xxxviii.     A  filament  removed  with  forceps ;  the  distal  end 
is  not  shown. 

Leber  considered  that  coagulation  products  from  the  conjunctiva! 
sac  became  anchored  to  an  abrasion,  and  gradually  grew  by  accretion. 
He  pointed  out  that  the  epithelium  grows  over  the  filament  for  a 
certain  distance. 

Uhthoff  and  Fischer  regarded  the  filaments  as  fibrinous  coagula 
derived  from  the  fluids  of  the  inflamed  cornea,  their  peculiar  shape 
being  due  to  their  inherent  elasticity. 

Czermak  succeeded  in  reproducing  similar  bodies  experimentally 
from  mucous  filaments. 

Hess  first  completely  investigated  them,  and  his  conclusions  are 
undoubtedly  correct,  and  can  be  easily  confirmed.  He  removed  them, 
together  with  the  portion  of  epithelium  from  which  they  sprang. 
Here  there  is  a  triangular  elevation  of  the  epithelium,  from  the  apex  of 
which  the  filament  projects  (Figs.  119, 120).  At  the  base  of  the  triangle 


1 84 


THE    PATHOLOGY    OF   THE    EYE 


a  tendency  to  torsion  is  seen,  which  increases  towards  the  apex.  The 
cells,  with  their  nuclei,  become  stretched  out  and  elongated,  and  finally 
coiled  into  spiral  fibrillae.  Nuclei  are  often  absent,  or  do  not  stain,  for 
a  considerable  distance.  The  neighbouring  epithelium  of  the  cornea  is 
often  pathologically  altered,  being  vacuolated,  or  containing  hyaline  or 
pigmented  inclusions.  Groups  of  sixty  or  more  nuclei  may  also  be 
found  heaped  together.  Mitotic  figures  are  absent,  and  Hess  attri- 
butes these  abnormal  groups  to  amitotic  division,  such  as  occurs  in 


FIG.  120. — FILAMENTARY  KERATITIS. 

After  Hess.     A  filament  removed  with  a  keratome ;    the  distal  end  is  artifi- 
cially spread  out,  so  as  to  show  the  structure. 

degenerating  cells.  These  degenerated  cells  often  form  the  main  part 
of  the  knob  in  which  the  filament  ends.  The  whole  is  bathed  in 
mucoid  material. 

The  spiral  arrangement  is  probably  due  to  the  movements  of  the 
lid.  Treacher  Collins  has  suggested  that  the  filaments  originate  in  the 
partition  wall  between  two  vesicles.  As  these  increase  in  size  the  wall 
is  pushed  forwards,  and  when  the  vesicles  burst  a  filament  of  epithelium 
projects  from  the  surface. 


THE    CORNEA  185 

Hess  describes  a  different  form  of  filament  which  occurs  only  at  the 
site  of  discission  wounds.  These  are  clear,  with  a  central  core,  and 
consist  of  hyaline  material  with  a  few  leucocytes,  but  no  epithelial 
cells.  They  are  not  attached  to  the  epithelium,  but  pass  deeply  into 
the  wound.  They  are  attributed  to  vitreous  which  has  been  pressed 
forth  from  the  puncture. 

LEBER. — B.  d.  o.  G.,  Heidelberg,  1882,  1889.  UHTHOFF. — A.  f.  O.,  xxix,  3,  1883. 
FISCHER. — A.  f.  O.,  xxxv,  3,  1889.  C/.ERMAK. — K.  M.  f.  A.,  xxix,  1891.  *HESS. — A.  f.  O., 
xxxviii,  i,  1892;  xxxix,  2,  1893.  NUEL. — A.  d'O.,  xiii,  1893.  COWELL  AND  GRIFFITH. — 
T.  O.  S.,  xiv,  1894.  TREACHER  COLLINS. — Lancet,  1900. 


INFLAMMATION 

KERATITIS  IN  GENERAL 

Bowman  (1849)  first  drew  attention  to  the  minute  changes  in  the 
cornea  in  inflammation,  and  he  was  followed  by  Virchow  (1852)  and 
his  pupil  Strube  (1851),  His  (1856),  Weber  (1858),  Rindfleisch  (1859), 
and  Langhans  (1861).  At  this  period,  only  the  fixed  corneal  corpuscles 
were  known,  and  all  cellular  changes  were  attributed  to  them,  though 
their  dependence  for  nutrition  upon  fluid  (lymph)  exuded  from  the 
peripheral  blood-vessels  was  recognised  (Virchow,  1843).  The  dis- 
covery by  v.  Recklinghausen  (1862)  of  wandering  cells,  resembling 
white  corpuscles,  altered  the  whole  aspect  of  the  subject,  and  the 
enormous  increase  of  cells  in  inflammatory  conditions  could  no  longer 
be  attributed  without  further  proof  to  the  corneal  corpuscles,  v.  Reck- 
linghausen placed  pieces  of  cornea  in  the  lymph-sac  of  a  frog,  and  found 
that  they  were  rapidly  permeated  with  cells  ;  and  since  this  took  place 
in  absolutely  dead  corneal  material,  it  was  obvious  that  the  cells  were 
derived  from  without.  Moreover  if  particles  of  cinnabar  were  placed 
in  the  lymph-sac,  they  were  taken  up  by  the  cells,  and  were  also 
present  in  the  intra-corneal  cells — a  further  proof  that  these  had 
wandered  into  the  tissue. 

Cohnheim  (1867 — 1873)  showed  in  a  series  of  experiments  that 
white  corpuscles  leave  the  blood-vessels  in  large  numbers  during  in- 
flammation, and  wander  at  large  in  the  tissues.  By  marking  the 
leucocytes  with  cinnabar  (v.  Recklinghausen)  or  aniline  blue  (Cohn- 
heim) it  was  possible  to  demonstrate  that  they  wandered  into  the 
cornea  in  situ,  in  the  same  manner  as  into  the  dead  cornea  in  the 
frog's  lymph-sac.  Cohnheim  went  too  far  in  denying  any  activity 
in  the  corneal  corpuscles,  an  opinion  which  met  with  vigorous  and 
insufficiently  restrained  opposition  from  Strieker,  Bottcher,  and 
others. 

Eberth  (1876)  paid  special  attention  to  the  part  played  by  the 
corneal  corpuscles  in  regeneration,  which  was  also  investigated  by 
Senftleben  (1878),  who  considered  that  the  corpuscles  only  reproduced 
themselves,  and  never  gave  origin  to  pus-corpuscles.  Ranvier  thought 
that  the  function  of  the  leucocytes  in  corneal  wounds  was  to  afford 
nourishment  to  the  proliferating  corneal  cells. 


186  THE    PATHOLOGY    OF   THE    EYE 

Strieker  had  already  asserted  the  activity,  not  only  of  the  corneal 
cells,  but  also  of  the  ground  substance ;  and  Heitzmann  affirmed  the 
presence  here  of  living  material  which,  during  inflammation,  returned 
to  an  embryonic  cellular  condition.  Grawitz  went  so  far  as  to  assert 
the  presence  of  "  sleeping  "  cells,  which  awoke  to  activity  under  the 
stimulus  of  inflammation,  and  became  manifest  as  lanceolate  figures 
(Spiessfiguren,  vide  infra),  much  as  crystals  are  formed  from  a  solution. 
His  suggestions  and  criticisms  of  earlier  work  met  with  great  and 
successful  opposition  from  Klemensiewicz,  Yamagiva,  Orth,  Lubarsch, 
Schnaudigl,  and  others. 

Meanwhile  the  bacteriological  aspects  of  the  subject  had  been  in- 
vestigated, first  by  Nassiloff  (1870),  later  by  Eberth  (1873),  Orth  (1873), 
Leber  (1891),  and  others.  Leber's  experiments  on  mycotic  keratitis 
produced  in  rabbits  by  aspergillus  were  especially  productive  of  results 
from  the  morphological  standpoint.  Finally,  Councilman  (1899)  nas 
thrown  much  light  upon  the  characters  of  the  wandering  cells.  He 
has  shown  that  fifteen  minutes  after  central  infection  of  the  cornea 
with  staphylococci  granular  leucocytes  are  found  in  the  conjunctiva  ; 
these  are  also  the  first  to  appear  in  the  cornea,  and  form  the  majority 
of  the  wandering  cells.  In  eighteen  to  twenty-four  hours  isolated 
non-granular  leucocytes  are  found  in  the  peripheral  part,  and  in  four 
days,  lymphocytes.  The  latter  occur  only  in  the  lymph-channels  at 
the  periphery,  and  probably  come  from  lymphatic  glands,  and  not  from 
the  blood.  After  five  days  plasma-cells  appear  in  the  outer  third  of  the 
cornea.  These  and  the  lymphocytes  show  mitotic  figures,  which  are 
absent  in  the  other  wandering  cells. 

It  will  be  seen,  therefore,  that  the  cornea  was  early  recognised  by 
general  pathologists  as  specially  adapted  for  the  investigation  of  the 
fundamental  processes  which  go  on  in  all  cases  of  inflammation.  All 
kinds  of  animals  (frog,  fish,  birds,  guinea-pig,  rabbit,  dog,  etc.)  and  all 
sorts  of  stimuli  (suture  in  the  cornea  or  bulb,  cauterisation — thermal  or 
chemical, — inoculation  of  bacteria  or  moulds,  etc.)  were  used.  The 
first  effect  is  a  grey  opacity  at  the  site  of  injury,  appearing  in  a  few 
hours,  and  rapidly  followed  by  hypersemia  at  the  limbus,  doubtless  due 
to  the  irritating  effect  of  soluble  products  carried  outwards  by  the 
lymph-stream.  The  reaction  is  most  rapid  with  bacterial  inoculations. 
The  second,  less  constant  effect  is  a  peripherial  opacity,  most  marked 
near  the  primary  injury,  but  involving  the  whole  circumference  when 
this  is  central,  though  here  it  is  most  marked  above  and  below.  It  is  a 
prominent  feature  in  induced  keratitis,  where  the  original  focus  lies  in 
the  anterior  chamber  or  some  other  part  of  the  eye  ;  it  then  often 
involves  the  whole  cornea.  When  the  injury  is  central,  the  peripheral 
opacity  may  clear  up  from  the  outside,  leaving  a  dense  infiltration  ring 
around  the  central  focus.  This  is  caused,  according  to  Leber,  by 
positive  chemotaxis.  At  the  site  of  inoculation,  the  organisms  increase 
and  cause  death  of  a  limited  area  of  the  tissue,  owing  to  the  concentra- 
tion of  the  toxins.  Diluted  toxins  diffuse  to  the  periphery  of  the 
cornea,  and  lead  to  hypersemia  with  increased  permeability  of  the 
vessel  walls  to  plasma,  and  emigration  of  leucocytes.  The  latter  are 
attracted  by  positive  chemotaxis  to  the  focus  of  irritation.  Before  they 


THE    CORNEA 


187 


reach  the  necrotic  area,  however,  and  at  a  variable  distance  according 
to  the  virulence  of  the  organisms,  the  leucocytes  are  paralysed  and  die. 
Here  they  accumulate  and  form  the  infiltration  or  migration  ring. 
They  wage  war  upon  the  bacteria  in  two  chief  ways  :  (i)  directly  upon 
any  outlying  organisms  by  phagocytosis,  and  upon  their  toxins  by 
counteracting  chemical  products ;  (2)  upon  the  necrotic  tissues  by 
forming  pepsin-like  ferments  which  dissolve  these  and  thus  facilitate 
their  removal  mechanically  into  the  conjunctival  sac,  and  by  absorption 
into  the  lymph-stream.  There  are  also  leucocytes  in  the  central  area, 
but  these  are  derived  directly  from  the  conjunctival  sac.  Owing  to  the 
flatness  of  the  cornea  and  the  arrangement  of  the  laminae  the  migra- 


FIG.  121. — KERATITIS.      x   120. 

Oblique  section,  to  show  corneal  corpuscles  and  infiltration  with  leucocytes. 
The  epithelium  is  seen  above. 

tion  zone  is  rather  a  ring  than  a  cup,  but  this  is  notably  influenced  by 
details,  as  we  shall  see  in  treating  of  hypopyon  ulcers  (q.  v.). 

On  account  of  the  multiplication  of  the  organisms  in  the  lymph- 
channels  between  the  corneal  lamellae  in  cases  of  acute  infection,  where 
the  protective  migration  of  leucocytes  is  inefficient,  fine  grey  radial 
stripes  with  straight  branches  can  often  be  made  out  with  a  corneal 
loupe.  Similarly  the  outer  edge  of  the  infiltration  zone  fades  off,  owing 
to  the  diminishing  concentration  of  the  toxins,  in  less  acute  cases. 

Microscopically  the  leucocytes  and  corneal  corpuscles  are  much 
altered  by  their  position  between  the  lamellae,  etc.,  so  that  they  are  no 
longer  easily  differentiated,  especially  in  vertical  sections.  In  tangential 
sections  the  more  deeply  staining  nuclei  of  the  leucocytes  distinguish 
them  from  those  of  the  fixed  cells,  though  the  degeneration  of  the  latter 
often  leads  to  their  nuclei  becoming  round  and  taking  up  the  stain 


i88 


THE    PATHOLOGY   OF   THE    EYE 


unusually  well.  The  wandering  cells  lie  in  the  lymph-spaces  between 
the  lamellae  and  around  the  nerves,  and  also  between  the  fibrils  inside 
the  lamellae.  They  are  therefore  compressed  into  long,  straight, 
spindle-  or  lance-shaped  figures,  which  may  be  called  inflammatory 
spindles  (Entziindungsspiesse).  These  are  often  marshalled  in  parallel 
rows,  which  cross  one  another  at  various  angles  (Fig.  122).  Owing  to 
the  compression  to  which  they  are  subjected,  the  polymorphic  nuclei 
are  characteristically  altered,  and  little  resemble  their  usual  form. 
They  appear — though  it  is  probably  merely  an  appearance — to  be 
broken  up  into  round,  oval,  and  very  frequently  club-shaped  masses, 
which  are  less  often  in  the  middle  of  the  cells  than  at  the  poles.  Many 
are  united  by  extremely  fine  drawn-out  filaments ;  others  seem  to  be 


FIG.  122. — KERATITIS.      x    180. 

Oblique  section  from  same  specimen  as  Fig.  121.  The  nuclei  of  the  corneal 
corpuscles  (faintly  stained)  and  of  the  leucocytes  are  seen;  many  of  the  latter  show 
the  arrangement  of  inflammatory  spindles. 


isolated.  The  nuclear  masses  and  filaments  are  very  rich  in  chromatin, 
and  stain  very  intensely  with  nuclear  stains.  The  cytoplasm  contains 
granules,  which  are  generally  neutrophile  (especially  in  the  rabbit), 
occasionally  eosinophile  (especially  in  the  pigeon),  and  this  demon- 
strates their  leucocytic  nature  (Schnaudigl).  The  granules  are  shown 
in  frozen  sections  of  fresh  tissue  stained  for  half  a  minute  with 
Ehrlich's  triacid  mixture,  or  in  hardened  tissue  stained  by  haema- 
toxylin  and  eosin ;  in  the  moist  chamber  amoeboid  movements  have 
been  observed  in  the  cells  (Orth). 

The  leucocytes  are  derived  from  two  sources :  (i)  those  normally 
present  in  the  cornea,  reinforced  during  inflammation  by  others  which 
have  emigrated  from  the  peripheral  vessels  ;  (2)  those  which  have  made 


THE    CORNEA  189 

their  way  in  from  the  conjunctival  sac.  The  latter  enter  chiefly  where 
the  epithelium  is  lost,  and  in  less  degree  where  the  epithelial  cells  are 
more  or  less  degenerated  and  separated  from  each  other ;  they  show 
little  tendency  to  invade  the  intact  epithelium.  Descemet's  membrane 
is  a  complete  bar  to  their  progress,  so  that  none  are  derived  from  the 
anterior  chamber,  nor  do  intra-corneal  leucocytes  contribute  to 
hypopyon.  Most  of  the  cells  are  polymorphonuclear  cells,  though 
other  leucocytes  are  also  found,  as  well  as  lymphocytes. 

The  corneal  corpuscles  are,  for  the  most  part,  easily  distinguished 
from  the  leucocytes:  (i)  the  nuclei  are  round,  oval,  curved,  or  horse- 
shoe-shaped ;  (2)  they  are  larger ;  (3)  they  stain  more  faintly  with 
nuclear  stains  ;  (4)  there  are  no  colourable  granules  in  the  cytoplasm ; 
(5)  they  often  show  mitotic  figures.  Round  leucocytes  often  lie  in  the 
concavity  and  elsewhere  in  the  neighbourhood  of  the  fixed  cells,  but 
separated  from  them  by  a  clear  zone.  They  are  best  seen  in  gold- 
chloride  preparations,  in  which  the  cytoplasm  of  the  corneal  corpuscles 
is  stained  (Orth).  Other  corpuscles,  especially  near  the  primary  focus, 
show  degenerative  changes — swelling,  vacuolation,  fatty  degeneration, 
or  complete  necrosis.  Under  these  conditions  fragmentation  of  the 
nuclei  may  occur,  so  that  appearances  of  multinuclear  cells  arise 
(Bottcher),  though  it  is  doubtful  if  these  are  not  leucocytes. 

The  ground  substance  of  the  cornea  probably  plays  a  purely  passive 
part,  for  the  active  changes  described  by  Strieker,  Heitzmann,  and 
especially  Grawitz  cannot  be  considered  proved,  and  are  unlikely  on 
general  principles.  The  lamellae  are  forced  apart  by  increased  exuda- 
tion, and  their  constituent  fibrillae  are  separated  by  leucocytic  infiltra- 
tion. Chemical  changes  follow,  partly  due  to  the  action  of  toxins  and 
partly  to  the  ferment  action  of  the  leucocytes,  resulting  in  softening 
and  solution. 

The  first  evidence  of  repair  is  seen  in  the  development  of  new 
vessels  from  the  part  of  the  limbus  lying  nearest  to  the  focus,  or,  when 
this  is  central,  from  the  whole  periphery.  Their  chief  function  is  that 
of  supplying  the  necessary  material  for  making  good  the  loss  of 
substance.  They  lie  in  the  most  superficial  layers  of  the  cornea, 
between  the  epithelium  and  Bowman's  membrane  ;  but  in  severe  or 
prolonged  inflammations  they  are  also  formed  beneath  Bowman's 
membrane.  They  are  at  first  mere  endothelial  tubes,  accompanied  by 
a  small  amount  of  granulation  tissue,  including,  according  to  Orth, 
fibres  which  stain  with  elastic-tissue  stains.  They  may  ultimately 
atrophy,  forming  fine,  solid,  cellular  threads ;  or  some  may  remain 
permanently,  developing  a  definite  adventitia. 

Other  signs  of  regeneration  are  seen  in  the  mitotic  division  of  the 
corneal  corpuscles,  from  which  the  scar  tissue  is  formed,  though  the 
plasma-cells  may  take  part  in  the  process.  Long  spindle-shaped  cells 
or  regeneration  spindles  (Regenerationsspiesse,  Senftleben)  are  formed, 
often  with  many  thick  processes.  The  scars  after  many  inflammatory 
conditions  differ  from  those  after  wounds  in  being  more  fibrous,  the 
cells  being  smaller  and  more  compact,  with  deeper  staining,  more  rod- 
like  nuclei.  Regeneration  of  the  epi-  and  endo-thelium  takes  place  by 
karyokinetic  division  of  the  cells. 


igo  THE    PATHOLOGY   OF   THE    EYE 

BOWMAN. — Lectures  on  Parts  concerned  in  Operations  upon  the  Eye,  London,  1849. 
VIRCHOW. — Virchow's  Archiv,  iv,  1852.  STRUBE. — Inaug.  Diss.,  Wiirzburg,  1851.  His  — 
Wiirzb.  Verhdl.,  iv,  Basel,  1856.  WEBER. — Virchow's  Archiv,  xv,  1858.  RINDFLEISCH. — 
Virchow's  Archiv,  xvii,  1859.  LANGHANS. — Z.  f.  rat.  Med.,  xii,  1861.  v.  RECKLINGHAUSEN. 
— Die  Lymphgefasse  u.  ihre  Beziehung  zu  dem  Bindegewebe,  1862  ;  Virchow's  Archiv, 
xxviii,  1863.  COHNHEIM — Virchow's  Archiv,  xl,  1867;  xlv,  1869;  Ixi,  1874;  Neue  Unter- 
such.  iiber  Entziindung,  1873.  STRICKER. — Stud,  aus  d.  Inst.  f.  exp.  Path.,  Wien,  1869; 
Wien.  med.  Jahrb.,  1873,  1874,  1876,  1880 ;  Vorl.  iiber  allg.  Path.,  1883.  BOTTCHER. — 
Virchow's  Archiv,  Iviii,  1873;  Ixii,  1875.  FUCHS. — Virchow's  Archiv,  Ixvi,  1876  (Biblio- 
graphy). EBERTH. — Unters.  path.  Inst.,  Zurich,  1874,  1875;  Virchow's  Archiv,  Ixvii,  1876; 
Virchow's  Festschrift,  ii,  1891.  SENFTLEBEN. — Virchow's  Archiv,  Ixxii,  1878.  RANVIER. — 
Comptes  rendus,  cxxv,  cxxvi,  1897.  HEITZMANN. — Mikr.  Morph.  des  Thierkorpers,  Wien, 
1883.  GRAWITZ. — Atlas  d.  path.  Histologie,  1893  ;  Virchow's  Archiv,  cxliv,  1896  ;  Deutsche 
med.  Woch.,  1896;  Ueber  Leben  u.  Tod,  Greifswald,  1896.  KLEMENSIEWICZ. — Ueber 
Entziind.  u.  Eit.,  Jena,  1893.  YAMAGIVA. — Virchow's  Archiv,  cxxxvii,  1894.  ORTH. — 
Nachr.  d.  Ges.  d.  W.  in  Gottingen,  Math.-phys.  Cl.,  1897.  LUBARSCH.— Ergebnisse,  iii, 
1897;  Deutsche  med.  Woch.,  1898.  SCHNAUDIGL. — A.  f.  O.,  xlvii,  1899.  NASSILOFF. — 
Virchow's  Archiv,  1,  1870.  EBERTH. — Zur  Kenntniss  d.  bakter.  Mykosen,  1873.  ORTH. — 
Virchow's  Archiv,  Iviii,  1873.  *  LEBER. — Die  Entstehung  der  Entziindung,  Leipzig,  1891. 
*  COUNCILMAN. — Jl.  Boston  Soc.  of  Med.  Sc.,  1899.  *  ORTH. — Lehrbuch,  gte  Lieferung, 
Berlin,  1902. 


PHLYCTENULAR  KERATITIS 

Phlyctenular  keratitis  has  been  examined  microscopically  even  more 
rarely  than  the  same  form  of  conjunctivitis,  of  which  it  is  merely  an 
extension.  It  affects  the  superficial  layers  of  the  cornea,  which 
correspond  morphologically  with  the  conjunctival  layer,  though  whether 
the  anterior  layers  of  the  substantia  propria  are  of  conjunctival  origin  is 
doubtful,  and  not  very  probable. 

Iwanoff  (1869)  found  nodules  of  cells  upon  Bowman's  membrane, 
raising  the  epithelium  ;  they  also  surrounded  the  nerve-fibrils  passing 
through  this  membrane,  which  might  be  partially  destroyed.  The 
infiltration  around  the  nerves  was  held  to  account  for  the  pain  and 
photophobia. 

Leber  and  Wagenmann  (1897)  confirmed  the  presence  of  sub- 
epithelial  nodules ;  the  epithelium  was  infiltrated  and  ultimately 
destroyed,  and  superficial  vascularisation  occurred. 

Baas  found  nodules  below  Bowman's  membrane  in  a  case  of 
prolonged  scrofulous  keratitis  with  superficial  opacities.  The  nodules 
consisted  of  new-formed  fibrous  tissue,  with  flattened  nuclei  lying 
parallel  to  the  surface ;  they  involved  either  the  whole  or  only  the 
deeper  part  of  Bowman's  membrane,  having  either  a  broad  basis  of 
attachment  to  the  substantia  propria  or  a  narrow  pedicle  (cf.  Fig.  115). 
These  nodules  were  obviously  late  scars,  and  but  little  stress  can  be  laid 
upon  the  observations,  especially  as  the  patient  was  also  syphilitic,  and 
had  specific  choroiditis.  So  far  as  they  go  they  tend  to  show  that  the 
phlyctenules  are  endogenous,  the  aggregations  of  leucocytes  lying 
originally  below  Bowman's  membrane. 

The  cases  reported  by  Gruber  and  Hertel  are  even  more  open  to 
question.  The  first  was  in  a  child  aged  two  and  a  half  months,  and 
was  a  deep  purulent  ulcer ;  the  second  was  in  a  shrinking  eye  with 
leucoma  adhserens.  In  the  latter  the  changes  were  also  beneath 
Bowman's  membrane,  which  was  fibrillar  and  broken  through  in  places. 


THE    CORNEA  191 

The  site  of  the  phlyctenules  was  marked  by  dense  infiltration,  the 
epithelium  being  lifted  up  and  partially  destroyed.  There  were  several 
small  subepithelial  nodules  in  the  conjunctiva. 

Augstein  reported  the  case  of  a  child  with  pannus  scrofulosus  and 
multiple  infiltrates  in  the  cornea.  There  was  infiltration  and  formation 
of  new  connective  tissue  in  the  superficial  lamellae.  Bowman's 
membrane  was  to  a  large  extent  destroyed.  Vessels  were  found  both 
in  the  superficial  layers  and  deep  in  the  cornea. 

Seo  and  Yamaguchi,  in  a  case  of  fascicular  keratitis  and  pannus 
scrofulosus  (q.  v.),  found  small  deposits  of  fibrous  tissue  and 
connective-tissue  cells  lying  under  Bowman's  membrane,  which  was 
eroded,  in  the  otherwise  normal  parts  of  the  cornea.  The  most  super- 
ficial lamellae  were  either  intact  or  somewhat  thinned.  These  were 
doubtless  the  sites  of  former  phlyctenules,  and  confirm  Baas's  results. 

Very  little  stress  can  be  laid  upon  such  cases  as  these,  and  we  must 
await  the  opportunity  of  examining  an  early  uncomplicated  case  before 
the  pathological  anatomy  of  phlyctenular  keratitis  can  be  settled. 

IWANOFF. — B.  d.  o.  G.,  1869.  LEBER,  WAGENMANN. — B.  d.  o.  G.,  1897.  BAAS. — 
K.  M.  f.  A.,  xxxvi,  1898 ;  xxxviii,  1900.  GRUBER. — A.  f.  O.,  xlvi,  2,  1898.  HERTEL. — 
A.  f.  O.,  xlvi,  3,  1898.  AUGSTEIN. — Z.  f.  A.,  1902.  SEO  AND  YAMAGUCHI. — K.  M.  f.  A., 
xli,  1903. 

INTERSTITIAL  KERATITIS 

Interstitial  or  parenchymatous  inflammation  of  the  cornea,  in  the 
pathological  sense  of  the  term,  is  extremely  common  in  a  great  variety 
of  cases.  The  cases  of  true  interstitial  keratitis,  in  the  restricted 
clinical  sense,  which  have  been  examined  microscopically  are  very  few7, 
and  are  mostly  complicated  by  other  conditions  which  make  it  difficult 
to  determine  the  exact  anatomy  of  the  disease.  Even  amongst  the 
cases  examined,  a  large  proportion  of  those  described  as  parenchyma- 
tous keratitis  were  undoubtedly  tubercular.  This  raises  the  question  of 
the  true  aetiology  of  the  disease.  In  England  we  are  accustomed  to 
regard  the  typical  condition  as  of  syphilitic  origin,  and  no  satisfactory 
proof  has  been  brought  forward  that  this  view  is  incorrect.  The  same 
unanimity  of  opinion  does  not,  however,  prevail  upon  the  Continent. 
The  cases  of  Burstenbinder,  Zimmermann,  and  Schultze  will  therefore  be 
eliminated  from  this  section,  and  considered  under  "  Tubercle  of  the 
Cornea"  (q. v.). 

Almost  all  the  cases  of  syphilitic  interstitial  keratitis  occur  in  youth 
in  the  subjects  of  congenital  syphilis.  It  is  found,  however,  rarely  in 
acquired  syphilis  (Wordsworth,  Lang,  Juler,  Lawford),  and  is  then 
nearly  always  limited  to  one  eye  (Lawford).  Valude  has  collected  forty 
cases.  Both  in  congenital  and  acquired  syphilis  it  occasionally  takes 
the  form  of  an  annular  or  disciform  keratitis  (Fuchs,  Paukstat).  Cases 
of  delayed  congenital  interstitial  keratitis,  coming  on  in  adult  life,  also 
occur ;  they  are  also  more  commonly  unilateral  than  the  usual  type.  A 
deep  localised  interstitial  deposit  may  also  occur  in  acquired  syphilis ;  it 
may  possibly  be  gummatous.  In  a  case  recorded  by  Nettleship  it  dis- 
appeared in  eight  months  under  treatment. 


IQ2 


THE    PATHOLOGY   OF   THE    EYE 


There  is  also  a  difference  of  opinion  as  to  the  cases  of  true  interstitial 
keratitis.  v.  Michel  and  others  distinguish  between  a  primary  and  a 
secondary  interstitial  keratitis.  In  the  former  a  triangular  opacity 
appears  at  the  margin  of  the  cornea  and  gradually  spreads  over  the 
whole  area ;  it  is  often  followed  by  iritis,  keratitis  punctata,  etc.,  and  is 
ascribed  by  v.  Michel  to  syphilitic  affection  of  the  marginal  loops  of 
blood-vessels.  The  secondary  form  is  distinguished  by  marked  inflam- 
mation of  the  uveal  tract,  and  often  of  the  sclerotic,  more  particularly 
in  the  anterior  part  of  the  eye. 

Leber  and  his  pupils  regard  the  disease  as  invariably  secondary, 
following  uveitis.  The  frequency  with  which  anterior  choroiditis  can  be 
observed  ophthalmoscopically  in  the  less  affected  eye  in  these  cases  is 


FIG.  123. — INTERSTITIAL  KERATITIS.      x  60. 

From  a  specimen  by   Hancock.     The  infiltration  is  densest  in  the  posterior 
layers. 

strong  evidence  in  favour  of  this  view,  which  is  further  supported  by 
such  microscopical  details  as  are  available. 

Most  observers  have  found  the  principal  changes  in  the  deepest 
layers  of  the  substantia  propria  (Kriickow,  Meyer,  Fuchs,  E.  v.  Hippel) 
(Fig.  123). 

Kriickow  found  many  new-formed  vessels  here,  and  evidences  of 
degeneration  of  the  corneal  corpuscles — diffuse  staining,  swelling  of  the 
nuclei,  and  contraction  of  the  processes. 

Meyer  found  thickening  of  the  whole  cornea,  infiltration  of  the  deep 
layers  with  round  and  polygonal  cells,  often  massed  together,  vasculari- 
sation  of  the  same  area,  and  thickening  of  the  endothelium  on  Descemet's 
membrane.  The  iris  and  sclerotic  showed  infiltration,  lymphocytes 
being  grouped  into  nodules  in  the  iris,  but  there  were  no  giant-cells. 
This  condition  is  not  uncommon,  quite  apart  from  any  question  of 
tubercle. 


THE    CORNEA  193 

Fuchs  describes  similar  appearances  :  dense  infiltration  of  the  most 
posterior  layers  of  the  cornea,  so  that  they  sometimes  appear  as  if  trans- 
formed into  granulation  tissue  ;  numerous  newly  formed  blood-vessels  in 
the  posterior  and  middle  layers.  The  infiltration  at  the  margin  of  the 
cornea  is  continued  into  the  ligamentum  pectinatum,  the  iris,  and  the 
ciliary  body.  Fuchs  has  also  found  nodular  aggregations  of  lymphocytes. 
There  were  accumulations  of  leucocytes  upon  Descemet's  membrane, 
but  hypopyon  is  extremely  rare. 

E.  v.  Hippel  gives  an  exhaustive  account  of  two  eyes.  The  cornea 
varied  in  thickness  from  o'6  to  0*66  mm.,  the  surface  being  undulating. 
There  were  leucocytes  between  the  basal  epithelial  cells,  and  upon 
Bowman's  membrane,  which  was  normal  except  at  the  periphery,  where 
there  was  a  layer  of  vascular  connective  tissue.  The  whole  substantia 
propria  showed  changes,  which  were  most  marked  in  the  deep  layers 
and  near  the  angle  of  the  anterior  chamber.  These  consisted  in  fibril- 
lation of  the  lamellae,  dilatation  of  the  interlamellar  spaces,  infiltration 
with  round-cells,  and  vascularisation  of  the  deep  layers  and  the  peri- 
pheral zone.  The  endothelium  was  intact.  There  were  tubercle-like 
nodules  in  the  peripheral  and  deepest  parts  of  the  cornea,  invading  the 
angle  of  the  anterior  chamber  and  infiltrating  the  ligamentum  pectinatum 
iridis.  These  contained  several  typical  giant-cells,  surrounded  by  epithe- 
lioid  cells  and  an  outer  zone  of  round-cells.  There  were  two  giant-cells 
on  Descemet's  membrane.  There  was  marked  inflammatory  infiltration 
around  the  anterior  ciliary  vessels.  A  notable  feature  was  the  extensive 
inflammation  of  all  parts  of  the  eye,  especially  in  the  neighbourhood  of 
the  ciliary  vessels,  so  that  v.  Hippel  regards  the  condition  as  a  slight 
chronic  panophthalmitis.  It  may  well  be  doubted  whether  this  case 
was  not  in  reality  tubercular. 

Similar  cases  have  been  described  by  Wagenmann  and  Baas. 

Rare  cases  of  ulceration  of  the  cornea  in  severe  attacks  of  inter- 
stitial keratitis  have  been  recorded  (Treacher  Collins). 

An  attempt  has  been  made  to  reproduce  the  condition  experiment- 
ally. Infiltration  of  the  cornea  follows  various  injuries  to  the  eye,  as 
we  have  already  seen,  and  Raehlmann  has  paid  special  attention  to  the 
proliferation  of  the  corneal  cells  after  insertion  of  a  suture  into  the 
sclerotic.  Others  have  produced  infiltration  by  injury  of  the  endothe- 
lium, on  the  lines  of  Leber's  researches.  Samelsohn,  for  example, 
injected  ammonia  solution  into  the  anterior  chamber.  Mellinger  and 
Barri  conclude  that  interstitial  keratitis  is  due  to  changes  in  the  endo- 
thelium, but  the  condition  produced  by  such  experiments  is  transitory, 
and  disappears  when  the  endothelium  recovers.  It  is  doubtless  due,  as 
pointed  out  by  Leber,  primarily  to  oedema,  though  transient  inflam- 
matory infiltration  may  follow.  Wagenmann  and  Siegrist  produced  a 
parenchymatous  infiltration  of  the  cornea  by  section  of  both  long 
ciliary  and  some  of  the  short  posterior  ciliary  vessels.  It  commenced 
at  the  margin  and  spread  rapidly  over  the  cornea,  which  was  swollen 
and  cedematous.  The  endothelium  suffered  severely,  being  almost 
entirely  thrown  off  in  one  case.  The  lamellae  were  swollen  and  per- 
meated by  coagulable  fluid,  which  formed  fibrinous  networks,  especially 
at  the  periphery.  Infiltration  with  round-cells  and  vascularisation 

13 


194  THE    PATHOLOGY    OF   THE    EYE 

followed,  undergoing  retrograde  changes  later,  and  giving  place  to 
proliferation  of  the  corneal  cells  and  thickening  of  the  fibrillae.  These 
changes  are  probably  to  be  referred  to  the  oedema  following  loss  of 
endothelium,  itself  brought  about  by  malnutrition.  None  of  the  ex- 
periments can  be  regarded  as  affording  typical  examples  of  the  clinical 
form  of  interstitial  keratitis,  the  immediate  cause  of  which  is  yet  to 
seek. 

That  changes  occur  in  the  endothelium  in  interstitial  keratitis  is 
rendered  probable  by  E.  v.  Hippel's  fluorescei'n  experiments,  since  deep 
staining  frequently  occurs  in  these  cases  (see  also  Bihler,  Benson,  Graflin). 

Interstitial  keratitis  sometimes  follows  experimental  thyroidectomy 
in  animals,  as  I  have  observed  elsewhere.  The  condition  has  been 
discussed  by  Gley  and  Rochon-Duvigneaud.  It  is  not  uncommon  in 
dogs  after  distemper,  and  is  a  source  of  trouble  in  hunting  packs.  It 
has  also  been  observed  in  pheasants  (Treacher  Collins)  and  in  wild 
animals  kept  in  captivity,  e.  g.  bears  (Nuel). 

The  formation  of  new  vessels  in  interstitial  affections  of  the  cornea 
has  received  attention  from  Straub.  They  often  arise  in  cases  of 
experimental  infection  of  the  vitreous.  Straub  considers  they  are  due 
to  a"vaso-chemotactic"  influence — which  is  little  more  than  expressing 
the  fact  of  their  occurrence  in  other  words. 

WORDSWORTH. — R.  L.  O.  H.  Rep.,  ix,  i,  1876.  LANG. — T.  O.  S.,  xi,  1891  ;  xii,  1892. 
JULER. — Ophth.  Rev.,  xvii,  1898.  LAWFORD. — T.  O.  S.,  xx,  1900.  *  VALUDE. — Ann.  d'Oc., 
cxvii,  1897.  FUCHS,  PAUKSTAT. — K.  M.  f.  A.,  xxxix,  1891.  NETTLESHIP. — R.  L.  O.  H. 
Rep.,  xi,3,  1887.  KRUCKOW. — B.  d.  o.  G.,  1875.  MEYER. — Inaug.  Diss.,  Gottingen,  1887. 
•  FUCHS. — Text-book.  E.  v.  HIPPEL. — A.  f.  O.,  xxxix,  3,  1893;  xlii,  2,  1896;  xliv,  3,  1897. 
WAGENMANN. — A.  f.  O.,  xlii,  2,  1896.  BAAS. — A.  f.  O.,  xlv,  1898.  KAKO. — K.  M.  f.  A.,  xl, 
1902.  TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xi,  3,  1887.  RAEHLMANN. — Arch.  f.  exp. 
Path.  u.  Pharm.,  vii,  1877.  LEBER. — A.  f.  O.,  xix,  2,  1873.  SAMELSOHN. — B.  d.  o.  G.,  1886. 
MELLINGER. — A.  f.  O.,  xxxvii,  4,  1891.  BARRI. — Inaug.  Diss.,  Basel,  1895.  WAGENMANN. — 
A.  f.  O.,  xxxvi,  4,  1890.  BIHLER. — Munch,  med.  Woch.,  1899.  E.  v.  HIPPEL. — A.  f.  O., 
1'v,  3,  1902.  BENSON. — Ophth.  Rev.,  xxi,  1902.  GRAFLIN. — Z.  f.  A.,  ix,  1903.  PARSONS. — 
Jl.  of  Anat.  and  Phys.,  xxxv,  1901.  GLEY  AND  ROCHON-DUVIGNEAUD. — Arch,  de  Phys. 
norm,  et  path.,  1891. 


PANNUS 

Pannus  is  a  term  which  is  often  used  loosely  for  any  vascularisation 
of  the  cornea ;  it  should  be  reserved  clinically  for  the  special  types 
found  in  phlyctenular  conjunctivitis  and  in  trachoma,  the  latter  being 
the  more  characteristic.  In  each  case  there  is  not  merely  a  develop- 
ment of  new  vessels  in  the  cornea,  but  an  ingrowth  of  granulation 
tissue  from  the  limbus.  Opinions  differ  as  to  the  exact  situation  of 
the  ingrowth. 

In  phlyctenular  conjunctivitis  three  types  of  vascularisation  may 
occur :  (i)  the  vascularisation  of  an  ordinary  ulcer  (q.  v.)  ;  (2)  the 
vascular  fasciculus  (Fischer),  which  is  associated  with  an  advancing 
ulcer,  and  in  which  the  vessels  lie  in  a  depressed  furrow  representing 
the  cicatrised  path  of  the  ulcer;  (3)  pannus  scrofulosus  or  eczematosus, 
in  which  there  is  a  continuous  new  formation  of  tissue  upon  the  surface 
of  the  cornea,  developing  from  any  spot  upon  the  corneal  margin.  In 
(i)  and  (3)  the  condition  may  clear  up  completely,  leaving  no  opacity 


THE    CORNEA 


195 


behind ;  under  these  circumstances  the  vascular  tissue  is  superficial  to 
Bowman's  membrane.  In  (2)  usually,  and  in  (i)  and  (3)  frequently,  a 
permanent  opacity  is  left,  and  it  is  probable  that  here  Bowman's  mem- 
brane is  destroyed,  either  by  erosion  from  the  surface  and  invasion 
of  the  superficial  corneal  laminae,  or  perhaps  by  primary  invasion  of 
the  superficial  laminae  and  secondary  erosion  of  Bowman's  membrane 
(Baas). 

In  pannus  scrofulosus  Baas  found  an  ingrowth  ofvascular  granula- 
tion tissue  immediately  beneath  Bowman's  membrane,  which  showed 
fibrillation  and  erosion  from  beneath,  resulting  in  places  in  complete 
destruction.  He  regards  the  condition  as  merely  a  superficial  extension 
of  the  usual  disseminated  phlyctenular  process,  and  as  good  evidence 
of  the  endogenous  nature  of  the  process.  This  view  is  largely  discounted 


FIG.  124. — PANNUS  DEGENERATIVUS.      x  90. 

From  a  case  of  glaucoma.  Note  vessels  and  granulation  tissue  between  the 
degenerated  epithelium  and  the  intact  Bowman's  membrane.  The  substantia 
propria  is  infiltrated,  and  towards  the  periphery  vascularised. 


by  the  clinical  cases  in  which  no  opacity  remains ;  these  have  not 
yet  been  submitted  to  histological  examination.  It  is  more  probable 
that  the  deeper  invasion  is  secondary.  In  the  later  stages  the  cells 
become  spindle-shaped  and  more  densely  packed,  many  of  the  vessels 
being  obliterated,  sometimes  by  hyaline  degeneration. 

Seo  and  Yamaguchi  exhaustively  investigated  a  case  of  keratitis 
fascicularis  and  pannus  scrofulosus  in  a  tubercular  child  set.  2-^.  In 
the  area  of  infiltration  Bowman's  membrane  and  the  anterior  lamellae 
were  destroyed,  and  replaced  by  vascular  granulation  tissue,  upon  which 
lay  the  new-formed  epithelium.  The  advancing  edge  of  the  new  tissue 
burrowed  under  Bowman's  membrane,  eroding  it  from  behind.  The 
deeper  layers  of  the  substantia  propria  were  also  affected ;  there  were 
deep-lying  vessels  surrounded  with  leucocytes,  and  there  was  a  thick 


196 


THE    PATHOLOGY   OF   THE    EYE 


aggregation  of  round-cells  lying  upon  the  anterior  surface  of  Descemet's 
membrane,  resembling  the  "  posterior  abscess  "  of  hypopyon  keratitis. 

The  cases  examined  have  been  late  and  severe  cases.  In  all 
probability  the  earliest  vessels  and  granulation  tissue  of  the  ordinary 
vascular  fasciculus  make  their  way  between  the  epithelium  and 
Bowman's  membrane,  and  may  retrogress  without  permanent  injury  to 
the  cornea.  Anatomical  proof  is  as  yet  lacking. 

Pannus  degenerativus  (Baas)  is  a  term  applied  to  a  form  of  super- 
ficial pannus  which  occurs  in  blind,  degenerated  eyes,  such  as  result  from 
cyclitis,  glaucoma,  detached  retina,  etc.  Here  there  is  a  growth  of 
highly  vascular  granulation  tissue  immediately  beneath  the  epithelium 
and  lying  upon  Bowman's  membrane,  wrhich  is  usually  intact,  but  often 


FIG.  125. — PANNUS  DEGENERATIVUS.      x   120. 

From  the  same  case  as  Fig.  124.  Note  the  degenerative  and  cedematous 
changes  in  the  epithelium  and  the  large  islands  of  epithelium  lying  in  the  granula- 
tion tissue. 


folded  (Fig.  124).  Around  the  plexus  of  fine,  dilated  vessels  are 
numerous  lymphocytes,  which  later  disappear,  giving  place  to  spindle- 
shaped  cells,  which  gradually  become  more  and  more  compact,  with 
simultaneous  obliteration  of  the  finer  vessels.  Still  later,  there  is 
extensive  hyaline  degeneration,  with  more  or  less  complete  disappear- 
ance of  nuclei.  The  epithelium  is  usually  thickened,  and  shows 
degenerative  changes ;  islets  of  epithelial  cells  are  seen  in  the  midst  of 
the  homogeneous  material  in  sections,  being  probably  irregular  pro- 
cesses cut  across  (Fig.  125).  The  epithelial  cells  are  often  vacuolated, 
or  contain  fatty  globules,  and  are  frequently  epidermoid  in  the  superficial 
layers.  The  homogeneous  material  may  be  flat,  but  more  commonly  is 
wavy  upon  the  surface.  Bowman's  membrane  may  also  be  eroded  and 


THE    CORNEA 


197 


destroyed  in  these  cases,  and  the  substantia  propria  often  shows  vascu- 
larisation  and  other  changes  due  to  the  glaucoma,  etc. 

Pannus  degenerativus  is  naturally  the  form  which  has  most  often 
been  examined.  It  was  first  described  by  Miiller,  and  afterwards  by 
Bonders,  Althoff,  Iwanoff,  and  others,  and  was  figured  in  Pagenstecher 
and  Genth's  Atlas. 

In  pannus  trachomatosus  the  new-formed  tissue  starts  as  usual  at 
the  limbus,  but  always  in  the  upper  part,  and  extends  over  the  cornea. 
In  the  recent  stage  it  is  thin — pannus  tennis,  and  often  very  vascular — 
pannus  vasculosus.  If  it  has  acquired  considerable  thickness  it  is  called 
pannus  crassus  or  carnosus,  the  extreme  condition  being  sometimes  called 
pannus  sarcomatosus,  a  term  to  be  avoided.  An  old  pannus  with  much 


FIG.  126. — PANNUS  DEGENERATIVUS.      x   120. 

From  an  eye,  blind  ten  years,  with  detached  retina,  dislocated  lens,  etc.  Note 
the  laminated  mass  of  epithelium,  over  which  the  ordinary  basal  cells  pass,  the 
surface  being  kept  fairly  level  by  degeneration  of  the  mesial  layers  of  prickle-cells. 
Bowman's  membrane  appears  to  split  at  the  edges  of  the  lens-shaped  mass.  Many 
polymorphonuclear  leucocytes  are  seen  amongst  the  epithelial  cells. 

cicatricial  tissue  and  few  vessels  is  called  pannus  siccus.  Occasionally  a 
dense  white  or  yellow  scar  is  formed,  resembling  a  leucoma,  but  con- 
fined to  the  superficial  tissues;  or  small  white  spots  appear  in  the 
pupillary  area,  close  to  the  delicate  blood-vessels  (Fuchs).  These  also 
are  superficial,  and  may  be  removed  by  scraping.  In  progressive  pannus 
the  opacity  extends  beyond  the  vessels,  which  run  vertically  downwards, 
parallel  to  each  other,  without  anastomosing.  In  the  regressive  stage, 
the  vessels  extend  a  short  distance  beyond  the  opacity.  Pannus  may 
involve  the  whole  cornea,  and  in  these  cases  the  vessels  enter  from  all 
sides,  anastomose  with  each  other,  and  often  have  varicose  dilatations. 
Pannus  trachomatosus  is  not  caused  through  continuity,  since  the 


198  THE    PATHOLOGY   OF   THE    EYE 

conjunctiva  bulbi'is  usually  normal,  but  by  contiguity  with  the  affected 
lid.  It  is  not  merely  due  to  the  roughness  of  the  lid,  since  the  same 
amount  of  roughness  may  be  present  in  other  diseases  without  pro- 
ducing pannus.  The  limbus  is  the  most  vascular  part  of  the  bulbar 
conjunctiva,  and  is  therefore  most  apt  to  be  inflamed.  The  inflammation 
spreads  centripetally  into  the  cornea,  owing  to  the  prevalent  direction  of 
the  blood-  and  lymph-streams.  The  inflammation  is  induced  by  con- 
tinual contiguity  with  the  diseased  lid,  since  the  upper  part  of  the 
cornea  is  covered  by  the  lid  both  by  night  and  by  day.  The  roughness 
doubtless  contributes  to  the  infection  by  producing  minute  epithelial 
abrasions,  etc. 

Pannus  trachomatosus  is  capable  of  complete  retrogression,  so  that 
the  cornea  can  re-acquire  its  normal  transparency.  This  is  strong 
evidence  that  in  the  early  stages  the  vessels  are  insinuated  between  the 
epithelium  and  Bowman's  membrane,  leaving  the  latter  intact.  This 
stage  rarely  comes  under  observation  microscopically,  but  is  described 
and  figured  by  Fuchs ;  but  whether  the  description  and  figure  were 
derived  from  a  case  of  trachoma  can  only  be  inferred.  If  so,  it  in  every 
respect  resembles  the  early  stage  of  pannus  degenerativus. 

The  later  stages  are  best  described  by  Raehlmann,  who  has  had 
unusual  opportunities  of  investigating  trachoma  in  all  its  forms.  He 
found  the  epithelium  normal,  and  even  free  from  infiltration  by  leuco- 
cytes, except  quite  late.  Bowman's  membrane  was  also  intact,  though 
more  obviously  fibrillar  than  normal,  and  all  the  pathological  changes 
were  beneath  it.  Here  there  was  great  infiltration  of  the  substantia 
propria  with  lymphocytes,  which  were  most  closely  packed,  and  pene- 
trated deepest  into  the  tissues  at  the  upper  part,  gradually  fading  off, 
and  implicating  only  the  superficial  layers  as  the  centre  of  the  cornea 
was  approached.  Penetrating  the  upper  part  of  this  area  were  numer- 
ous new-formed  vessels,  many  of  the  capillaries  having  no  recognisable 
walls,  other  vessels  having  merely  an  endothelial  wall,  sometimes 
covered  by  a  thin  coating  of  connective  tissue.  The  direction  and 
distribution  of  these  vessels  has  been  already  mentioned. 

The  actual  substantia  propria  could  scarcely  be  recognised,  the 
laminae  being  separated  and  split  up  into  fibrillae  by  very  dense  lympho- 
cytic  infiltration.  The  addition  of  these  foreign  elements  leads  to 
thickening  of  the  cornea,  so  that  the  normal  furrow  at  the  periphery  is 
absent.  In  places  Raehlmann  found  nodular  aggregations  of  lympho- 
cytes, resembling  follicles,  and  in  every  respect  similar  to  the  tracho- 
matous  nodules  of  the  conjunctiva.  These  tended  to  invade  Bowman's 
membrane  and  the  epithelium,  which  were  raised  over  them ;  and  this 
condition  might  be  so  pronounced  as  to  cause  considerable  heaping  up 
of  the  tissue,  so  that  the  normal  furrow  was  not  only  filled  in,  but 
actually  replaced  by  a  swelling.  In  these  more  advanced  cases  Bow- 
man's membrane  was  destroyed,  and  replaced  by  a  layer  of  adenoid 
tissue,  consisting  of  a  fibrillar  network  containing  lymphocytes,  richly 
supplied  with  blood-vessels.  The  epithelium  was  then  also  invaded  by 
wandering  cells.  The  tissue  therefore  tends  more  and  more  to  assume 
the  character  of  trachomatous  conjunctiva,  and  pannus  trachomatosus 
must  be  regarded  as  an  invasion,  not  only  of  simple  granulation  tissue, 


THE    CORNEA 


199 


but  also  of  specific  trachoma  follicles.  The  infiltration  of  the  epithe- 
lium leads  to  its  being  loosened  and  often  cast  off,  or  rubbed  off  by  the 
rough  lid.  Hence  ulcers  frequently  occur,  generally  at  the  free  border 
of  the  pannus,  more  rarely  elsewhere.  Fragments  of  Bowman's  mem- 
brane may  remain,  but  it  is  for  the  most  part  reduced  to  a  fine 
basement  membrane,  or  even  this  may  disappear,  the  cylindrical  epi- 
thelium lying  directly  upon  the  adenoid  tissue.  There  are  naturally 
more  follicles  at  the  limbus,  but  they  are  also  found  towards  the  central 
part  of  the  cornea. 

As  already  mentioned,  the  pannus  may  entirely  disappear,  leaving  a 
clear  cornea.  In  the  more  severe  cases  cicatrisation  takes  place,  com- 
mencing in  the  neighbourhood  of  the  vessels.  The  round-cells  slowly 
diminish  in  number,  and  are  seen  to  lie  between  long  fine  fibres,  which 
apparently  fuse  into  thicker  homogeneous  laminae,  amongst  which  there 
are  a  few  fixed  spindle-cells. 

In  pannus  of  long  duration  the  deeper  layers  consist  of  these  cica- 
tricial  sclerosed  lamellae,  whilst  the  superficial  layers  are  still  adenoid 
and  contain  follicles,  and  the  epithelium  is  studded  with  mucous  cells 
in  all  its  layers.  Ultimately  the  whole  of  the  adenoid  tissue  and 
infiltration  disappear. 

MULLER. — Gesammelte  Schriften,  i,  Leipzig,  1872.  DONDERS. — See  ALTHOFF.  RITTER. 
—A.  f.  O.,  iv,  i,  1858.  ALTHOFF. — A.  f.  O.,  viii,  i,  1862.  IWANOFF. — Klin.  Beobacht. 
aus  d.  Augenheilanstalt  zu  Wiesbaden,  iii,  1866.  RAEHLMANN. — A.  f.  O.,  xxiii,  3,  1887. 
*  BAAS. — K.  M.  f.  A.,  xxxviii,  1900.  BIETTI. — Ann.  di  Ott.,  xxxi,  1902;  K.  M.  f.  A.,  xli, 
Beilageheft,  1903. 

SYPHILIS 

Interstitial  keratitis  is  described  elsewhere  (v.  p.  191).  Other 
syphilitic  affections  of  the  cornea — gummatous,  etc. — have  not  been 
examined  microscopically.  Extension  of  gummatous  cyclitis  and  scle- 
ritis  into  the  cornea  and  anterior  chamber  have  certainly  been  observed 
(e.  g.  Parsons),  but  there  are  no  differential  characteristics.  The 
corneal  lamellae  are  swollen  and  oedematous,  and  are  separated  by 
infiltrating  plugs  of  round-cells,  which  also  intrude  themselves  between 
the  fibrillae  of  the  lamellae.  The  whole  tissue  is  softened  and  necrotic, 
staining  more  or  less  diffusely. 

PARSON'S. — T.  O.  S.,  xxii,  1902 ;  R.  L.  O.  H.  Rep.,  xv,  3,  1903. 


TUBERCLE 

Tubercle  of  the  cornea  is  nearly,  if  not  quite,  invariably  a  secondary 
extension  from  the  uveal  tract.  The  posterior  layers  of  the  cornea  are 
associated  embryologically  with  the  uveal  tract,  hence  it  is  not  surprising 
that  the  disease  sometimes  assumes  the  typical  features  of  the  clinical 
form  of  interstitial  keratitis.  Cases  of  this  type  have  been  examined 
microscopically  by  Bongartz,  Burstenbinder,  Zimmermann,  Schultze, 
and  others  (see  "Tubercle  of  the  Iris").  Other  cases  assume  the 
form  of  a  sclerosing  keratitis,  whilst  yet  others  appear  as  deeply  situated 
discrete  opacities  (Hartridge  and  Griffith). 


200  THE    PATHOLOGY    OF   THE    EYE 

Haensell,  in  1879,  produced  an  eruption  of  tubercles  in  the  corneae  of 
rabbits  and  guinea-pigs  by  inoculation.  He  doubts,  however,  the 
existence  of  primary  tuberculosis  of  the  cornea,  and  in  some  experi- 
ments upon  rabbits  in  which  I  inoculated  the  cornea  with  virulent 
cultures,  I  failed  to  obtain  any  result  unless  the  anterior  chamber  was 
inoculated.  The  rabbits  have  been  kept  over  two  years  and  are  still 
quite  healthy.  At  the  same  time  rare  clinical  cases  favour  the  view 
that  primary  tubercle  of  the  cornea  does  occur.  The  question  is  one 
of  extreme  importance,  and  merits  further  research.  Bach  describes 
primary  tubercle  in  the  form  of  nodules  at  the  limbus  or  in  the  most 
peripheral  parts  of  the  cornea  itself.  They  slowly  invade  the  cornea, 
leaving,  after  healing,  a  greyish-white  tongue-like  opacity.  Greeff 
records  primary  tubercular  ulceration  of  the  cornea  from  auto- 
inoculation  by  the  finger-nail  of  a  tuberculous  patient.  It  slowly 
enlarged,  with  strong  vascularisation,  showing  no  tendency  to  heal, 
thus  resembling  the  torpid  vascular  ulcers  of  the  cornea  in  the  presence 
of  lupus  of  the  face. 

The  cornea,  however,  is  a  bad  culture  medium  for  the  bacillus, 
which  can  scarcely  ever  be  found  in  the  lesions.  The  parenchymatous 
type  is  attributed  by  Bach  to  the  action  of  the  toxins.  Proof  of  the 
tubercular  nature  of  the  complaint  can  only  be  afforded  by  inoculation 
of  the  rabbit's  anterior  chamber,  even  histological  examination  rarely 
affording  decisive  diagnosis. 

In  Hartridge  and  Griffith's  case  the  cornea  was  infiltrated  near  its 
posterior  aspect  and  just  within  Descemet's  membrane  by  small,  round, 
deeply  staining  cells ;  vessels  were  seen  penetrating  this  tissue.  At 
one  place  near  the  centre  there  was  an  interruption  of  Descemet's 
membrane,  and  fibro-cellular  tissue  connected  the  substantia  propria 
with  a  similar  tissue  occupying  the  pupillary  area.  The  diagnosis 
rested  upon  the  presence  of  typical  tubercle  systems  in  the  iris,  ciliary 
body,  etc.  The  case  of  Bongartz  was  similar — caseation  was  absent, 
but  tubercle  bacilli  were  demonstrated. 

In  other  cases  there  were  aggregations  of  epithelioid  and  giant-cells, 
without  caseation,  between  the  lamellae,  and  especially  along  Uescemet's 
membrane  (Zimmermann).  In  Zimmermann's  case  there  was  round- 
celled  infiltration  throughout  the  cornea.  Bacilli  were  demonstrated  in 
the  corneal  tubercles  as  well  as  in  other  parts  of  the  eye. 

Baumgarten's  case  was  very  advanced,  and  showed  extensive 
caseation.  The  whole  cornea  was  transformed  into  a  mass  of  caseating 
tubercles,  with  granulation  tissue.  Descemet's  membrane  was  per- 
forated in  several  places,  and  the  tissue  was  here  continuous  with  the 
iris.  It  was  proved  clinically  that  the  disease  was  an  extension  from 
the  conjunctiva. 

In  Schultze's  case  there  was  a  tubercle  containing  bacilli  in  the 
angle  of  the  anterior  chamber.  Probably  E.  v.  Hippel's  cases 
(v.  p.  193)  belong  to  the  same  category. 

The  differences  observed  in  the  cases  doubtless  depend  upon  many 
factors,  especially  the  number  and  virulence  of  the  bacilli,  the  stage  of 
the  disease,  and  above  all  the  relative  inertness  of  the  tissue.  Schieck 
has  confirmed  the  earlier  experiments  of  Baumgarten  upon  rabbits, 


THE    CORNEA  201 

which  show  that  groups  of  epithelioid  cells  occur  at  the  site  of 
inoculation,  but  that  these  are  liable  to  be  covered  over  and  obscured 
by  lymphoid  cells. 

BAUMGARTEX. — A.  f.  O.,  xxiv,  3,  1878.  HAENSELL. — A.  f.  O.,  xxv,  4,  1879.  *  PAXAS 
AND  VASSAUX. — A.  d'O.,  v,  1885.  BONGARTZ. — Inaug.  Diss.  Wiirzburg,  1891.  STRUBELL. 
— Inaug.  Diss.  Wiirzburg,  1894.  HEYDEMAXX. — Inaug.  Diss.  Greifswald,  1894.  HART- 
RIDGE  AND  GRIFFITH. — T.  O.  S.,  xv,  1895.  DEXIG. — A.  of  O.,  xxvii,  1898.  BURSTEX- 

BIXDER. A.  f.  O.,  xli,   I,   1895.        ZlMMERMAXX. A.  f.  O.  xli,    I,    1895.       SCHL'LTZE. A.  f.  A., 

xxxiii,  1896.     SCHIECK. — Ziegler's  Beitrage,  xx,  1896.     BACH. — A.  f.  A.,  xxxii,  1896. 


LEPROSY 

The  eyeball  is  very  frequently  attacked  in  leprosy.  The  cornea  is 
always  attacked  secondarily,  since  it  contains  no  vessels  (Lie).  Three 
types  of  inflammation  are  found  here,  a  superficial  punctate  and  a  deep 
parenchymatous  keratitis,  and  the  formation  of  granulomatous  tumours. 

In  the  superficial  punctate  keratitis,  small  grey  nodules  are  found 
under  the  epithelium  at  the  periphery,  and  they  gradually  spread 
towards  the  centre.  They  consist  chiefly  of  aggregations  of  lepra 
bacilli,  and  bacilli  may  be  found  free  in  the  lymph-spaces,  with  or 
without  proliferation  of  the  neighbouring  cells  (Neisser,  Lie,  Uhlenhuth). 
Lie  was  unable  to  find  mitoses  in  the  corneal  corpuscles,  the  inflam- 
matory cells  consisting  chiefly  of  polymorphonuclear  leucocytes  and 
endothelial  cells  derived  from  new  vessels. 

The  deep  parenchymatous  keratitis  is  always  secondary  to  anterior 
uveitis,  the  infection  spreading  from  the  ciliary  body  and  along  the 
deep  episcleral  vessels.  It  differs  from  ordinary  interstitial  keratitis  in 
that  it  does  not  clear  up,  but  permanent  discoloration  remains. 

Lepromata,  or  granulation-tissue  tumours,  are  caused  by  infection 
spreading  from  the  episclera,  so  that  they  originate  in  the  limbus.  A 
crescentic  opacity  appears  at  the  periphery  of  the  cornea  and  spreads 
towards  the  centre,  and  upon  this  nodules  develop,  which  may  cover 
the  whole  cornea  (Babes).  The  growth  is  chiefly  outwards,  but  the 
depth  of  infiltration  varies  much.  In  the  episclera  the  fixed  tissue- 
cells  proliferate  moderately  (Lie),  and  the  nodules  are  surrounded  by 
large  thin-walled  vessels.  Meyer  and  Berger  describe  a  leproma  in 
which  there  were  many  large  epithelioid  and  spindle-shaped  cells  lying 
in  a  reticulum,  so  that  it  resembled  a  sarcoma.  The  granulation  tissue 
contains  round  and  spindle-shaped  clumps  of  bacilli.  The  surface  may 
ulcerate,  but  usually  the  epithelium  is  very  resistant  in  all  three  types, 
and  may  proliferate  downwards,  forming  epithelial  plugs. 

A  similar  case  has  been  reported  by  Chiarini  and  Fortunati. 

The  substantia  propria  also  offers  considerable  resistance  to  infiltra- 
tion, but  it  may  be  ultimately  entirely  destroyed,  Descemet's  membrane 
alone  remaining  intact.  Bowman's  membrane  easily  succumbs,  the 
epithelium  lying  on  a  thin  layer  of  connective  tissue. 

Franke  and  Delbanco's  cases  were  of  the  maculo-anaesthetic  type, 
but  showed  similar  histological  features. 

NEISSER.— Virchovv's  Archiv,  ciii,  1886.  MEYER  AND  BERGER. — A.  f.  O.,  xxxiv,  4, 
1888.  POLLOCK.— Leprosy  as  a  Cause  of  Blindness,  London,  1889.  PHILIPPSOX. — B.  z.  A., 


202  THE    PATHOLOGY    OF   THE    EYE 

xi,  1893.  CHIARINI  AND  FORTUNATI. — Ann.  di  Ott.,  xxiii,  1894.  WINTERSTEINER. — 
Wiener  klin.  Woch.,  1895.  DOUTRELEPONT  AND  WOLTERS. — Arch.  f.  Derm.,  1896.  BABES. — 
Untersuchungen  u.  den  Leprabacillus,  etc.,  1898.  *  BORTHEN  AND  LIE. — Die  Lepra  des 
Auges,  Leipzig,  1899.  FRANKE  AND  DELBANCO. — A.  f.  O.,  1,  2,  1900.  ULENHUTH  AND 
WESTPHAL. — Klin.  Jahrbuch,  Jena,  1900.  NEVE. — Brit.  Med.  Jl.,  1900. 

SUPERFICIAL  PUNCTATE  KERATITIS 

Superficial  punctate  keratitis  was  first  described  by  Fuchs  (1889), 
later  by  Stellwag  v.  Carion,  Reuss  (keratilis  maculosa),  Adler  (keratitis 
subepithelialis) ,  and  others.  Unlike  reticular  and  nodular  opacities 
(q.  v.)  the  disease  commences  with  inflammatory  symptoms,  and 
resembles  herpes  febrilis.  Minute  grey  spots  occur  at  once  or  after  an 
interval  of  days  or  weeks.  They  vary  from  ten  to  twenty  to  over  a 
hundred,  and  are  often  in  rows  or  groups,  generally  in  the  central  part 
of  the  cornea.  They  are  quite  superficial,  and  the  epithelium  is  raised 
by  them. 

Nuel  has  examined  corneal  fragments  microscopically.  He  found 
dense  networks  of  fibres,  staining  deeply  with  alum  carmin,  in  the 
substantia  propria  beneath  Bowman's  membrane.  The  lamellae  were 
redematous  and  homogeneous,  and  the  lymph-spaces  were  dilated. 
The  filaments  were  between  the  lamellae,  and  were  apparently  con- 
nected with  the  corneal  corpuscles.  They  were  massed  under  Bowman's 
membrane  and  diminished  in  number  deeper  in  the  cornea.  The  epithe- 
lium was  osdematous,  and  showed  degenerative  changes ;  at  the  spots 
there  were  often  cystic  spaces  containing  granular  material.  Occa- 
sionally Bowman's  membrane  was  destroyed  and  replaced  by  a  network 
of  fibres.  Nuel  regards  the  filaments  as  fibrin  undergoing  hyaline 
degeneration.  In  similar  pathological  conditions — though  differing 
clinically — he  has  found  aggregations  of  cocci. 

Herbert  states  that  a  form  of  superficial  punctate  keratitis  is  common 
in  Bombay.  He  was  able  to  isolate  an  encapsuled  bacillus  from  the 
epithelial  scrapings.  The  capsules  are  3*2  ju  long  by  1*6  /i  broad  ;  the 
bacillus  stains  feebly,  and  is  decolourised  by  Gram. 

FUCHS. — Wien.  klin.  Woch.,  1889.  STELLWAG  v.  CARION. — Wien.  klin.  Woch.,  1889. 
REUSS. — Wien.  klin.  Woch.,  1889.  ADLER.— C.  f.  A.,  xiii,  1889.  MARCUS  GUNN. — T.  O.  S., 
x,  1890.  BRONNER. — T.  O.  S.,  xii,  1892.  NUEL. — A.  d'O.,  xiv,  1894;  xvi,  1896.  HERBERT. 
— Ophth.  Rev.,  xx,  1901. 

SCLEROSING  KERATITIS 

In  scleritis  if  a  nodule  is  situated  near  the  margin  of  the  cornea  an 
opacity  develops  in  the  deeper  layers  of  the  latter.  It  is  triangular, 
with  the  apex  towards  the  centre  of  the  cornea.  Other  spots  may  also 
develop  in  the  cornea.  The  thinner  apex  of  the  opacity  may  clear  up, 
but  the  base  remains  permanently  and  becomes  bluish  white  like  the 
sclerotic;  hence  the  term  sclerosing  keratitis  (v.  Graefe).  With  re- 
current attacks  of  scleritis  the  opacity  gradually  advances,  and  may 
invade  the  whole  cornea  except  a  small  central  area. 

Microscopically  in  severe  scleritis  the  substantia  propria  of  the 
cornea  becomes  infiltrated  at  the  periphery  (see  Fuchs'  '  Text-book/ 


THE    CORNEA 


203 


fig.  64).      Vascularisation  takes  place,  with  the  deposition  of  fibrous 
tissue,  which  renders  the  cornea  opaque. 


PURULENT  KERATITIS 

The  intact  epithelium  offers  an  insurmountable  obstacle  to  the  in- 
vasion of  the  cornea  by  almost  every  organism  which  occurs  in  the  con- 
junctival  sac.  A  notable  excep- 
tion is  the  gonococcus,  which  is 
able  successfully  to  attack  the 
normal  epithelium,  disintegrate 
it,  and  invade  the  substantia 
propria.  The  diphtheria  bacillus 
can  probably  act  in  the  same 
manner,  but  in  each  case  it  is 
necessary  for  the  organisms  to 
remain  undisturbed  in  contact 
with  the  epithelium  for  a  con- 
siderable time.  There  are,  how- 
ever, many  conditions  which 
assist  the  entry  of  bacteria. 
Minute  abrasions  from  foreign 


-:.          ^«*      j^.  _^m^  v    ^pL2?    ^r  - 


FIG.  127. — ACTION  OF  COCAIN  ON  THE 

EPITHELIUM. 

Fuchs,  T.  O.  S.,  xxii.  Prolonged  action  of 
cocain  before  enucleation.  Note  the  swelling 
and  oedema  of  one  of  the  superficial  layers. 


bodies,  etc.,  are   common,   and 

the  denuded  surface  offers  little 

resistance  to  invasion.     In  other 

cases  the  resistance  of  the  epithelium  itself  is  diminished  or  abrogated 

by  drying,  as  in  xerotic  conditions,  or  by  actual  necrosis  due  to  deficient 

nutrition,  as  in  keratomalacia.      Further,  cedema  may  lead  to  desqua- 

mation,  or   desquamation    of 

the  entire  surface  may  be  due 

to  neuro-paralytic  keratitis. 

A  more  minute  examina- 
tion of  the  epithelium  in  these 
various  conditions  will  readily 
prove  the  weakening  of  this, 
the  first  line  of  defence.  We 
have  already  examined  the 
state  of  the  epithelium  in 
oedema  and  the  desquamation 
resulting  from  it  (v.  p.  175). 
An  analogous  condition  is 
found  after  prolonged  instilla- 
tion of  cocain,  especially  if 
the  lids  are  not  closed  in  the 
intervals.  The  epithelium  be- 
comes opaque  and  dull,  and  is  finally  thrown  off.  The  superficial  layers 
swell  (Fig.i27)  and  become  loosened  (Fig.  128).  They  are  then  detached, 
and  a  remarkable  change  takes  place  in  the  basal  cells  (Fig.  129),  groups 


FIG.  128. — ACTION  OF  COCAIN  ON  THE  EPI- 


THELIUM. 


Fuchs,  T.  O.  S.,  xxii. 
layers  of  epithelium. 


Exfoliation  of  superficial 


204 


THE    PATHOLOGY    OF   THE    EYE 


of  which  become  changed  into  a  light  mass  with  shrunken  nuclei  scattered 
here  and  there.     In  consequence  of  the  alteration  of  the  basement  layer, 


srC 


FIG.  129. — ACTION  OF  COCAIN  ON  THE  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xxii.  Desquamation  of  the  superficial  layers.  Degeneration 
and  coalescence  of  groups  of  basal  cells,  leaving  free  nuclei.  This  would  eventuate 
in  total  desquamation  and  the  formation  of  abrasions. 

the  whole  epithelium  becomes  detached  from  Bowman's  membrane,  and 
may  be  exfoliated. 

The  epithelium  may  undergo  degenerative  changes  from  various 
other  causes,  resulting  in  partial  or  complete  atrophy  (v.  p.  225). 

Enough  has  been  said  to  show  the  extreme  importance  of  the  epi- 
thelium as  a  protective  mechanism,  and  also  the  multitudinous  ways  in 
which  its  vitality  may  be  affected.  Further,  the  nature  and  extent  of 
the  affection  varies  with  conditions,  both  local  and  general.  Added  to 


FIG.  130. — ULCER  OF  THE  CORNEA,      x  60. 

Infiltrated  edge  of  an  hypopyon  nicer.  Note  the  swelling  from  oedema  and 
infiltration.  Bowman's  membrane  is  continued  unchanged  for  a  considerable 
distance  beyond  the  epithelium. 

these  factors  is  the  variety  of  the  agents  of  attack,  the  nature  of  the  re- 
sultant ulceration   differing   with    the   organism.     The   relative   parts 


THE    CORNEA 


205 


played  by  all  these  factors  have  been  accurately  apportioned  in  very  few 
cases.  In  badly  nourished  corneas  ulceration  is  apt  to  be  deep,  leading 
to  early  perforation,  and  also  extensive,  resulting  in  wide-spread  necrosis. 
Such  septic  ulcers,  due  to  the  attack  of  ordinary  pyogenic  organisms, 


i«§@ki:i  :~&'**»ws£ 


FIG.  131. — ULCER  OF  CORNEA. 

Fuchs,  T.  O.  S.,  xxii.  Ingrowth  of  epithelium  between  the  lamellae  of  the 
cornea  at  the  edge  of  an  ulcer.  The  epithelial  cells  are  intermingled  with  leuco- 
cytes, which  also  invade  Bowman's  membrane. 

occur  after  injuries  in  asthenic  conditions  in   keratomalacia,  lagoph- 
thalmos,  keratitis  neuro-paralytica,  etc. 

In  the  commonest  form  of  suppurative  keratitis — the  corneal  ulcer 
— there  is  a  localised  necrosis  in  the  most  anterior  layers  of  the  cornea. 
The  sequestrum  is  partly  disintegrated  and  cast  off  into  the  conjunctival 
sac,  and  partly  adheres  to  the  surface  of  the  ulcer.  Usually  the  epi- 


FIG.  132. — ULCER  OF  CORNEA. 

Fuchs,  T.  O.  S.,  xxii.    Epithelium  growing  over  pus  and  necrotic  tissue,  which 
cover  the  floor  of  the  ulcer. 

thelium  is  destroyed  and  cast  off  over  an  area  considerably  larger  than 
the  ulcer  itself,  and  the  same  applies  to  Bowman's  membrane,  though 
this  is  not  always  destroyed  so  extensively  (Fig.  130).  The  epithelium, 
however,  rapidly  advances  towards  the  ulcer,  grows  over  its  edge,  and 


206  THE    PATHOLOGY   OF   THE    EYE 

even  penetrates,  sometimes  deeply,  between  the  separated  lamellae,  the 
epithelial  cells  often  mingling  intimately  with  the  pus-corpuscles 
(Fig.  131).  Not  only  so,  but  it  may  grow  over  the  slough  and  purulent 
lymph  which  covers  the  floor  of  the  ulcer  or  perforation,  and  may  even 
form  regular  cylindrical  basement  cells  reposing  upon  purulent  matter 
(Fuchs)  (Fig.  132).  Similarly  it  will  grow  over  blood-clot  which  may  be 
present.  When  the  final  line  of  demarcation  is  determined  and  the 
dead  material  is  completely  cast  off,  this  epithelium  will  of  course  suffer 
a  like  fate.  In  the  progressive  stages  the  ends  of  the  broken  lamellae  are 
swollen  by  oedema,  and  are  separated  by  masses  of  pus-cells,  which  also 
infiltrate  the  lymph-spaces  for  a  considerable  distance  around  and 
beneath  the  ulcer.  The  margins  of  the  ulcer  therefore  usually  project 
considerably  above  the  surface  of  the  cornea  (Fig.  133).  This  infiltrated 
area  appears  as  a  grey  zone  around  the  ulcer  (v.  p.  187).  When  the  dead 
material  has  been  thrown  off  the  ulcer  is  somewhat  larger,  but  the 
cloudiness  has  disappeared,  the  base  and  edges  are  smooth  and  trans- 
parent, and  the  regressive  stage  is  reached.  Meamvhile  vascularisation 
has  been  going  on,  and  cicatrisation  now  commences.  This  occurs  in 


FIG.  133. — MARGIN  OF  A  CORNEAL  ULCER. 
Fuchs,  T.  O.  S.,  xxii.     Swelling  of  the  edge  by  imbibition  of  fluid. 

exactly  the  same  manner  as  in  the  healing  of  corneal  wounds,  the  pro- 
cesses gone  through  by  the  epithelium  and  the  granulation  tissue  being 
identical  (v.  p.  151).  The  regenerative  changes  are  ill-marked  in  cases  of 
general  asthenia,  e.g.  in  keratomalacia  (Sachsalber). 

In  all  cases  of  acute  keratitis,  irritant  substances  diffuse  from  the 
cornea  into  the  anterior  chamber,  and  there  act  upon  the  blood-vessels 
of  the  iris  and  ciliary  body.  The  result  varies  in  degree,  but  the  change 
in  character  of  the  aqueous  is  often  very  marked.  From  being  a  fluid 
which  contains  only  O'i2  per  cent,  of  proteid  material,  it  becomes  highly 
albuminous,  owing  to  the  injury  inflicted  upon  the  walls  of  the  uveal 
vessels.  Leucocytes  are  also  present,  and  a  fibrinous  coagulum  may  be 
formed  upon  the  posterior  surface  of  the  cornea  and  often  upon  the 
anterior  surface  of  the  iris.  When  the  action  of  the  toxins  is  more 
intense  the  number  of  leucocytes  is  enormously  increased,  and  the 
aqueous  becomes  cloudy.  These  subsequently  sink  to  the  bottom  of  the 
anterior  chamber  and  form  an  hypopyon.  The  typical  hypopyon  ulcer 
has  certain  specific  characters,  which  will  be  discussed  separately.  It 
need  only  here  be  emphasised  that  the  hypopyon  originates  from  the 
vessels  of  the  iris  and  ciliary  body,  and  not  from  the  cornea  ;  and  that 


THE    CORNEA 


207 


FIG.  134. — LEUCOMA  OF  CORNEA,      x  60. 

Scar  following  ulceration.  Note  the  "  levelling  tendency  "  of  the  epithelium  ; 
the  fibrillation  and  extensive  destruction  of  Bowman's  membrane;  the  irregularity  of 
the  scar  tissue  as  compared  with  the  deeper  intact  lamellae;  the  infiltration  and 
vascularisation  of  the  substantia  propria. 


FIG.  135. — LEUCOMA  OF  CORNEA,      x  60. 

Scar  two  months  after  abrasion,  which  was  followed  by  ulceration.  The  epithe- 
lium is  ill-formed ;  Bowman's  membrane  is  broken  up  and  displaced.  The  sub- 
stantia propria  shows  interstitial  infiltration  and  vascularisation,  almost  limited  to 
the  superficial  layers  (cf.  True  Interstitial  Keratitis,  Fig.  123). 


208  THE    PATHOLOGY    OF   THE    EYE 

it  is  therefore  sterile.  This  accounts  for  the  rapidity  with  which  it  is 
frequently  reabsorbed,  and  also  for  its  being,  unlike  pus  in  general,  rela- 
tively innocuous.  The  hypopyon  varies  greatly  in  consistence,  being 
usually  very  fluid,  but  occasionally  forming  a  dense  fibrinous  coagulum. 
The  latter  occurs  in  more  severe  cases,  and  is  less  readily  absorbed. 


FIG.  136. — ULCER  OF  CORNEA,      x  6. 

Adhesion  of  lens  to  cornea  after  an  injury,  followed  by  hypopyon  ulcer.  The 
centre  of  the  cornea  is  replaced  by  vascular  scar  tissue,  which  extends  backwards 
to  the  iris  and  lens.  The  lens  capsule  is  ruptured,  and  the  anterior  part  of  the 
cortex  is  infiltrated  with  leucocytes. 

Absorption  takes  place  principally  through  the  meshes  of  the  ligamentum 
pectinatum  iridis. 

SACHSALBER. — Z.f.  A.,  ix,  Erganzungsheft,  1903. 

HYPOPYON  ULCER 

The  typical  hypopyon  ulcer,  or  ulcus  serpens  (Saemisch),  is  a  greyish- 
white  or  yellow  disc,  occupying  nearly  the  centre  of  the  cornea.  The 
opacity  is  greater  at  the  edges  than  the  centre,  and  is  generally  well 
marked  in  one  special  direction.  Grey  striae  extend  from  the  margin  of 
the  disc  into  the  transparent  cornea.  There  is  severe  iritis,  with 
posterior  synechiae,  and  hypopyon. 

The  association  of  hypopyon  with  inflammation  of  the  cornea  was 
called  hypopyon  keratitis  by  Roser  in  1856.  Saemisch  recognised  the 
characteristic  tendency  of  the  typical  hypopyon  ulcer  to  affect  the 
superficial  layers  of  the  cornea  and  to  spread  over  the  surface ;  he 
therefore  called  it  ulcus  serpens  (1870).  Illustrations  of  the  condition 
appeared  in  the  atlases  of  Pagenstecher  and  Genth  (1875)  and  Wedl 


THE    CORNEA 


209 


and  Bock  (1886).  The  first  minute  anatomical  description  was  pub- 
lished by  Verdese  (1887),  and  it  is  interesting,  in  the  light  of  recent 
polemics,  to  note  that  he  describes  perforation  of  Descemet's  membrane 
without  complete  perforation  of  the  whole  cornea.  Experimental  in- 
vestigations were  carried  out  by  Verdese  (1889),  Silvestri  (1891),  Leber 
(1891),  and  cases  were  described  by  Wagenmann  (1892),  Marple  (1893), 
Fuchs  (1893),  Nuel  (1895).  In  1896  a  very  important  series  of  observa- 
tions was  published  by  Uhthoff  and  Axenfeld,  comprising  five  cases  of 
ulcus  serpens,  four  of  keratomalacia,  three  of  commencing  panopthal- 
mitis,  and  one  of  mycotic  keratitis.  More  recent  papers  by  Wagenmann, 
Green  and  Ewing,  Elschnig,  Druault  and  Petit,  E.  v.  Hippel,  Levy, 


FIG.  137. — HYPOPYON  ULCER,      x   io-5. 

There  is  very  extensive  ulceration  of  the  cornea,  the  floor  of  the  ulcer  con- 
sisting only  of  Descemet's  membrane  and  a  few  densely  infiltrated  lamellae  The 
lower  half  of  the  a.  c.  is  full  of  pus  ;  the  more  faintly  stained  part  is  chiefly  fibrin  ; 
the  lower  angle  contains  blood.  The  iris  is  intensely  inflamed.  On  the  anterior 
surface  of  the  lens  is  a  pigmented  tag,  the  remnants  of  a  posterior  synechia  which 
has  torn  away. 

Wintersteiner,  and  others,  deal  principally  with  details,  some  of  which 
cannot  yet  be  said  to  be  finally  settled. 

According  to  Fuchs,  the  earliest  stage  of  ulcus  serpens  is  a  dense 
infiltration  of  the  superficial  lamellae  in  about  the  centre  of  the  cornea. 
The  lamellae  over  the  infiltrate  swell  up  and  exfoliate,  so  that  a  flat  open 
ulcer  is  formed,  the  floor  of  which  consists  of  fibres  which  have  been 
heaved  up,  and  are  swollen  into  an  almost  homogeneous  mass,  amongst 
which  are  sparsely  scattered  pus-corpuscles.  It  is  only  at  the  margins 
of  the  ulcer  that  the  remains  of  the  infiltrate  can  be  distinguished,  and 
here  it  penetrates — appearing  in  cross  section  like  a  wedge — into  that 
portion  of  the  cornea  which  is  still  sound.  This  corresponds  with  the 

14 


2IO 


THE   PATHOLOGY    OF   THE    EYE 


yellow  advancing  border ;  it  keeps  insinuating  itself  farther  and  farther 
between  the  lamellae,  so  as  at  first  to  lift  them  up  and  then  detach  the 
superficial  layers.  Often  the  ulcer  advances  in  one  direction  only. 
The  progressive  portion  then  looks  like  a  yellow  crescent.  At  other 
parts  the  wedge-shaped  infiltrate  is  absent,  and  the  epithelium  extends 
over  the  edge  of  the  ulcer  and  on  to  its  floor.  This  part,  however,  is 
not  necessarily  healed,  and  the  epithelium  may  lie  on  dying  tissue  or 
debris.  The  lamellae  here,  indeed,  are  often  swollen  and  hyaline,  and 
contain  no  stained  corpuscles ;  consequently  they  are  probably  necrotic. 
The  same  applies  in  less  degree  to  many  of  the  deeper  lamellae. 

Bowman's  membrane  is  destroyed  over  the  ulcer,  and  is  often  split 
up  for  a  considerable  distance  beyond.     In  some  cases  the  lamellae  near 


FIG.  138. — ULCER  OF  CORNEA,      x  22. 

Edge  of  hypopyon  ulcer  ;  to  the  left  is  a  paracentesis  wound,  over  the  edges  of 
which  epithelium  is  growing.  The  inner  part  of  the  wound  is  filled  with  leuco- 
cytes. The  cornea  is  densely  infiltrated  with  polymorphonuclear  leucocytes,  which 
also  cover  the  iris  and  parts  of  the  back  of  the  cornea. 

the  ulcer  are  separated  by  fibrinous  coagula  (Uhthoff  and  Axenfeld). 
The  infiltration  around  the  ulcer  is  usually  fairly  uniform  in  all  the  cases 
which  have  been  examined,  extending  without  break  to  the  periphery  of 
the  cornea ;  i.  e.,  Leber's  (central)  infiltration  ring  is  usually  absent  in 
man.  This  is  probably  due  to  the  toxins  not  being  sufficiently  strong 
to  paralyse  the  leucocytes  even  in  the  immediate  neighbourhood  of  the 
ulcer,  a  view  which  is  supported  by  the  fact  that  most  cases  are  due  to 
pneumococci  (v.  infra),  whereas  Hertel  observed  the  infiltration  ring  in 
cases  of  streptococcic  ulcer. 

The  middle  layers  of  the  cornea  are  least  infiltrated.  As  Descemet's 
membrane  is  approached  the  infiltration  increases  rapidly,  so  that  a 
definite  posterior  -infiltration,  or  so-called  posterior  abscess,  is  formed. 


THE   CORNEA  211 

This  corresponds  in  situation  with  the  site  of  the  ulcer.  Its  origin  is  a 
subject  of  dispute.  Two  views  are  open,  viz.,  that  the  leucocytes  are 
derived  from  the  peripheral  vessels,  and  travel  inwards  (Wintersteiner) ; 
or  that  they  are  derived  from  the  hypopyon,  and  travel  forwards 
(Elschnig).  Now  it  is  a  well-established  fact  that  leucocytes  do  not 
pass  through  an  intact  Descemet's  membrane ;  hence  the  condition  of 
Descemet's  membrane  is  of  prime  importance  for  the  solution  of  the 
problem.  There  is  no  doubt  that  Descemet's  membrane  offers  great 
resistance  to  inflammatory  and  other  processes,  so  that  it  often  remains 
unbroken  when  all  the  other  layers  of  the  cornea  have  been  destroyed ; 
keratocele,  indeed,  depends  upon  this  fact.  All  observers  agree  that 
Descemet's  membrane  is  frequently  split  into  layers,  which  are  separated 


FIG.  139. — ULCER  OF  CORNEA,      x   n. 

Section  across  the  edge  of  an  hypopyon  ulcer.  The  ulcer  is  healing  and  is 
covered  with  irregular  epithelium.  The  floor  and  edges  are  vascularised.  The 
posterior  lamellae  of  the  cornea  are  intact  and  only  slightly  infiltrated.  The  base 
of  the  ulcer  is  formed  by  a  thick  layer  of  scar  tissue.  Nearer  the  centre  of  the 
ulcer  there  was  an  anterior  synechia. 

by  aggregations  of  leucocytes,  and  also  that  it  may  be  ultimately  broken 
through  (Fig.  140).  Wintersteiner  thinks  that  this  takes  place  from 
before  backwards.  Elschnig  and  his  followers  hold  that  early  perforation 
(Friihperforation)  of  Descemet's  membrane  is  a  conspicuous  feature  of 
ulcus  serpens,  and  that  it  is  due  to  attack  from  behind.  They  support 
this  idea  by  cases  in  which  the  opening  in  the  posterior  layers  of  the 
split  membrane  is  greater  than  that  in  the  anterior  layers.  This  con- 
dition is  also  described  as  an  internal  ulcer. 

As  already  mentioned,  Descemet's  membrane  was  perforated  in 
Verdese's  case.  This  and  other  cases  are  attributed  by  Petit  to  folds, 
which  often  look  like  perforations  in  sections.  Wagenmann,  E.  v. 


212  THE    PATHOLOGY   OF   THE    EYE 

Hippel,  and  Druault  and  Petit  found  deep  ulceration  with  normal 
Descemet's  membrane  ;  Uhthoff  and  Axenfeld,  Green  and  Ewing  found 
early  perforation.  Green  and  Ewing,  indeed,  support  the  exploded 
view  that  the  leucocytes  of  the  hypopyon  are  derived  from  the  cornea. 
It  is  an  important  fact  that  most  of  the  cases  with  perforation  of 
Descemet's  membrane  were  glaucomatous  eyes.  Greeff  brings  forward 
the  case  of  a  child  with  fairly  extensive  hypopyon  keratitis  who  died  of 
pneumonia.  There  was  a  well-developed  posterior  infiltration  with 
quite  intact  Descemet's  membrane.  He  cites  the  sterility  of  hypopyon 
as  an  argument  against  Elschnig's  view,  but  the  ferment  action  of 
leucocytes  is  not  due  to  organisms,  though  it  may  be  stimulated  by 
their  presence. 

Elschnig's  theory  is  supported  by  Fuchs,  but  it  can  be  scarcely  said 
to  be  proved  beyond  cavil. 

The  endothelium  is  often  absent  over  a  large  area,  especially  behind 
the  ulcer,  even  when  Descemet's  membrane  is  intact.  Uhthoff  and 
Axenfeld  found  giant-cell-like  masses  of  endothelium  free  in  the  hypo- 
pyon ;  in  other  places  leucocytes  separated  the  endothelium  from  the 


FIG.  140. — ULCER  OF  THE  CORNEA. 

Fuchs,  T.  O.  S.,  xxii.  Swelling  of  the  floor  of  the  ulcer  by  imbibition  of  fluid. 
Splitting  and  destruction  of  Descemet's  membrane  by  infiltration  from  behind 
("early  perforation").  Hypopyon. 

membrane.  The  cells  themselves  showed  pathological  changes — vacuo- 
lation,  faint  nuclear  staining,  etc.  Elsewhere  there  was  proliferation 
and  the  formation  of  stellate  cells.  The  leucocytes  often  adhere 
especially  in  the  neighbourhood  of  the  posterior  infiltration,  and  are 
continuous  with  it  when  Descemet's  membrane  is  perforated.  When 
the  membrane  is  split,  the  clefts  are  also  filled  with  leucocytes. 

The  hypopyon  was  at  first  thought  to  be  derived  from  the  cornea 
(Horner) ;  it  is  now  almost  universally  believed  to  come  from  the 
vessels  of  the  iris  and  ciliary  body  (Leber,  Uhthoff  and  Axenfeld,  Bach, 
Wagenmann,  etc.).  This  view  is  supported  by  the  presence  of  pigment 
granules  in  the  hypopyon  (Uhthoff  and  Axenfeld).  The  cause  of  the 
hypopyon  is  chemotaxis,  and  this  accounts  for  the  main  aggregation  of 
leucocytes  being  upon  the  back  of  the  cornea,  as  near  as  possible  to  the 
site  of  infection  ;  the  iris  is  often  covered  by  a  fibrinous  network,  con- 
taining relatively  few  cells,  so  that  possibly  most  of  the  leucocytes  are 
derived  from  the  ciliary  body  and  ligamentum  pectinatum  (Nuel). 
Chemotaxis  is  due  to  the  diffusion  of  toxins  only,  the  hypopyon  being 
sterile  as  long  as  Descemet's  membrane  is  intact  (Leber,  Uhthoff  and 
Axenfeld,  Bach,  etc.). 


THE    CORNEA  213 

Bacteriology. — The  credit  of  the  discovery  that  the  typical  ulcus 
serpens  is  due  to  pneumococci  rests  with  Uhthoff  and  Axenfeld  (1896), 
and  their  results  have  been  confirmed  by  investigators  in  all  parts  of 
the  world.  In  fifty  cases  they  found  pneumococci  only,  twenty-six 
times ;  mixed  with  other  organisms,  seven  times ;  other  bacteria  only, 
thirteen  times ;  no  bacteria,  four  times.  It  has  been  found  impossible 
to  reproduce  the  typical  ulcus  serpens  in  animals  by  inoculation. 
Neither  does  it  occur  in  its  typical  form  in  children,  in  whom  hypopyon 
ulcer  runs  a  different  and  usually  milder  course. 

The  ulcus  serpens  may  be  regarded  as  the  typical  form  of  hypopyon 
ulcer;  it  is  by  no  means  the  only  form.  Atypical  hypopyon  ulcer  is 
usually  due  to  other  pyogenic  organisms  than  the  pneumococcus — 
staphylococci,  streptococci,  bacilli,  etc.,  though  none  of  these  produces 
a  specific  type  of  ulcer.  There  is  a  greater  tendency  to  rapidly  invade 
the  deeper  layers  of  the  cornea.  Perforation  occurs  earlier,  and  the 
dangers  of  panophthalmitis  are  increased.  Quite  occasionally  pneumo- 
cocci are  present,  mixed  with  other  organisms ;  and  occasionally,  too, 
pneumococcic  infection  assumes  an  atypical  form  (Uhthoff).  In  gonor- 
rhceal  and  diphtherial  infection  the  corneal  processes  are  chiefly  due  to 
secondary  infection  by  other  pyogenic  bacteria,  the  gonococci  or  diph- 
theria bacilli  merely  facilitating  the  entry  of  these  by  the  action  of  their 
toxins.  The  same  applies  to  the  xerosis  bacilli  which  are  present  in 
such  large  numbers  in  many  xerotic  conditions,  keratomalacia,  etc., 
though  here  the  bacilli  probably  play  an  almost  purely  passive  part. 
The  most  interesting  form  of  atypical  hypopyon  keratitis  is  that  pro- 
duced by  the  Aspergillus  fumigatus,  which  demands  special  consideration 
(v.  infra). 

Hertel  has  exhaustively  investigated  nineteen  cases  of  suppurative 
keratitis;  eleven  were  cases  of  ulcus  serpens,  the  remainder  infected 
phlyctenular  ulcers,  etc.  In  ten  cases,  including  six  of  ulcus  serpens, 
the  pneumococcus  was  the  cause  in  eight,  being  mixed  with  staphylo- 
cocci in  one;  the  remaining  two  were  due  to  streptococci.  The  form  and 
size  of  the  ulcer  naturally  varied  with  the  duration ;  it  was  at  first  flat, 
the  advancing  edge  being  often  raised.  It  became  deeper  after  long 
duration,  but  here  too  the  progress  on  the  surface  was  greater  than  in 
depth.  The  size  also  varied  with  the  virulence  of  the  bacteria ;  in  two 
cases,  due  to  pneumococci,  it  was  extensive  after  three  days'  duration, 
and  in  one  of  these  the  cocci  killed  a  mouse  in  sixteen  hours.  The 
ulcer  was  also  greater  in  glaucomatous  eyes  than  in  others,  the  duration 
being  the  same. 

The  epithelial  defect  was  in  many  cases  much  more  extensive  than 
the  ulcer.  Besides  very  active  proliferation  of  epithelium  in  long- 
standing cases  (Uhthoff  and  Axenfeld),  Hertel  also  found  it  in  the  acute 
stage.  Mitoses  were  commoner  near  the  limbus  than  at  the  edge  of 
the  wound. 

Bowman's  membrane  was  occasionally  more  extensively  destroyed 
than  the  lamellae  ;  the  edge  was  broken  up  into  fibrillse.  The  substantia 
propria  showed  infiltration  and  necrosis,  the  latter  indicated  by  bad  stain- 
ing reaction.  The  necrotic  areas  showed  the  presence  of  cocci.  In  the 
freshest  cases  these  were  present  in  the  superficial  layers;  in  others 


214  THE    PATHOLOGY    OF   THE    EYE 

they  formed  spindle-shaped  masses  in  the  undermined  edges  of  the 
ulcer,  being  posterior  to  the  infiltration.  In  an  early  perforated  wound 
the  cocci  lay  in  large  numbers  in  the  necrotic  lamellae  directly  upon 
Descemet's  membrane.  They  were  not  seen  in  the  epithelium,  as  found 
by  Wagenmann.  The  reaction  zone  in  fresh  cases  was  at  a  little  dis- 
tance around  the  masses  of  cocci.  In  the  slighter  cases  a  line  of 
demarcation  was  formed  in  the  zone  of  infiltration.  In  the  more  severe, 
fresh  necrosis  and  infiltration  occurred,  and  here  the  cocci  might  be 
embedded  in  round-cells,  some  being  intra-cellular.  The  streptococcic 
cases  went  on  rapidly  to  perforation,  and,  as  already  mentioned,  Leber's 
infiltration  ring  was  seen  here. 

At  the  edges  of  the  necrotic  areas  degeneration  of  the  corneal 
corpuscles  was  manifested.  The  cell-processes  were  short  or  absent, 
and  the  nuclei  were  degenerated.  Necrosis  of  the  lamellae  was  shown 
by  fine  granulation  and  fibrillation.  In  the  surrounding  areas  inflam- 
matory spindles  (v.  p.  188)  were  present. 

Hertel  found  "  early  perforation  "  of  Descemet's  membrane  in  five 
cases ;  it  may  occur  as  early  as  two  and  a  half  to  three  days  after  the 
commencement  of  ulceration.  It  appeared  to  be  due  to  histolytic  effect 
of  the  leucocytes ;  in  two  cases  it  was  undoubtedly  due  to  erosion  from 
behind,  since  the  posterior  corneal  infiltration  was  absent  in  the  situa- 
tion of  the  apertures.  Hence  posterior  infiltration  is  not  essential  to 
the  development  of  early  perforation  of  Descemet's  membrane.  Hertel 
agrees  with  Elschnig  and  others  that  glaucoma  is  a  weighty  factor  in 
causing  early  perforation  ;  it  was  present  in  four  cases  out  of  six.  It 
doubtless  acts  through  defects  of  circulation  and  nutrition  (Elschnig)  as 
well  as  through  mechanical  means.  That  the  latter — mere  increase  of 
tension — can  lead  to  rupture  of  Descemet's  membrane  is  well  known 
(v.  Fig.  108). 

Hertel  regards  the  iris  as  the  main  source  of  the  hypopyon,  in 
opposition  to  Uhthoff  and  Axenfeld ;  the  changes  in  the  angle  and 
ciliary  body  were  less  marked.  It  contained  intra-  and  extra-cellular 
pigment  and  endothelial  cells ;  there  were  no  cocci  present. 

Romer's  experiments  with  antipneumococcic  serum  are  of  great 
interest. 

ROSER. — A.  f.  O.,  ii,  2,  1856.  SAEMISCH. — Das  Ulcus  serpens,  Bonn,  1870.  DINKLER. — 
A.  f.  O.,  xxxiv,  3,  1888.  VERDESE. — A.  d'O.,  vii,  1887;  ix,  1889.  SILVESTRI. — A.  f.  O., 
xxxvii,  2,  1891.  LEBER. — Die  Entstehung  der  Entziindung,  Leipzig,  1891.  WAGENMANN. — 
A.  f.  O.,  xxxviii,  3,  1892.  MARPLE. — A.  of  O.,  xxii,  1893.  GASPARRINI. — Ann.  di  Ott.,  xxii, 
1893.  FUCHS. — Text-book.  BASSO. — Internat.  Congress,  Rome,  1894.  NUEL.  — A.  d'O., 
xv,  1895.  SECONDI. — Clinica  moderna,  1895.  *  UHTHOFF  AND  AXENFELD. — A.  f.  O.,  xlii, 
i,  1896;  xliv,  i,  1897.  BACH  AND  NEUMANN. — A.  f.  A.,  xxxiv,  1897.  GREEN  AND  EWING. — 
T.  Amer.  O.  S.,  1896,  1898.  ELSCHNIG.— A.  f.  O.,  xlv,  1898.  E.  v.  HIPPEL.— A.  f.  O., 
xlvii,  1898.  DRUAULT  AND  PETIT. — A.  d'O.,  xix,  1899.  LUNDSGAARD. — K.  M.  f.  A., 
xxxviii,  1900.  PETIT. — K.  M.  f.  A.,  xxxix,  1901.  ELSCHNIG. — K.  M.  f.  A.,  xxxix,  1901. 
LEVY. — K.  M.  f.  A.,  xxxix,  1901.  WINTERSTEINER. — A.  f.  O.,  lii,  3,  1901.  ELSCHNIG. — 
A.  f.  O.,  liii,  2,  1901.  DOTSCH. — A.  f.  O.,  xlix,  2,  1900.  *  HERTEL. — A.  f.  O.,  liii,  2,  1901. 
ROMER. — A.  f.  O.,  liv,  i,  1902.  KRUGER. — Z.  f.  A.,  x,  1903. 


THE    CORNEA 


215 


MYCOTIC  KERATITIS 

Keratomycosis  aspergillina  (Schimmelpilzkeratitis)  affords  a  charac- 
teristic clinical  picture.  The  central  part  of  the  cornea  shows  an 
infiltration,  which  later  undergoes  superficial  disintegration,  and  is  dis- 
tinguished by  its  dry,  crumbling  surface.  A  grey  or  yellow  line  of 
demarcation  forms  about  this  area,  gradually  deepening  into  a  gutter, 
and  ultimately  leading  to  the  exfoliation  of  the  enclosed  portion  of 
cornea,  which  in  the  meantime  has  become  necrotic.  Hypopyon  is 
present,  but  the  irritative  symptoms  are  slight,  the  whole  course  being 
very  chronic. 

The  first  case  was  published  by  Leber  in  1879 ;  it  resulted  from  the 
husk  of  an  oat  grain  flying  into  the  eye.  The  second  case  was  pub- 
lished by  Berliner  (1882)  and  investigated  later  by  Uhthoff ;  it  followed 
a  blow  by  a  pear.  In  the  third  case,  described  by  Fuchs,  the  man  was 


FIG.  141. — MYCOTIC  KERATITIS.      x  20. 

From  a  photograph  by  Buchanan.  Meridional  section  of  cornea,  showing  area 
of  slough  penetrated  by  the  fungus,  zone  of  inflammatory  infiltration  surrounding 
the  slough,  and  the  margin  of  the  ulcerated  surface  from  which  the  slough  has 
been  separated. 

a  miller ;  he  had  an  attack  of  herpes  corneae  febrilis,  and  was  probably 
infected  by  the  flour  at  the  time  when  the  corneal  epithelium  was 
abraded.  Other  cases  have  been  reported  by  Uhthoff  and  Axenfeld, 
Schirmer,  Nobbe,  Wicherkiewicz,  etc.  In  Nobbe's  case  there  was  a 
perforating  wound  with  a  knife.  The  eye  was  excised  owing  to  sym- 
pathetic ophthalmia,  and  the  fungus  was  found  in  the  vitreous  (cf. 
Romer) . 

The  disease  is  due  to  a  mould,  the  Aspergillus  fumigatus,  and  s 
especially  characterised  by  the  tendencj^  to  the  formation  of  a  seques- 
trum (Fig.  141).  This  sequestrum  is  found  to  be  permeated  by  the 
mycelium,  which  forms  a  rich  network  of  fibrils,  showing  dichotomous 
division  (Fig.  142).  Fructification  is  absent  in  the  cornea,  probably 
because  the  cornea  is  below  the  optimum  temperature  for  growth.  The 
fibres  stain  well  with  haematoxylin,  better  with  Loffler's  m  ethylene 
blue  and  Weigert's  fibrin  stain,  not  at  all  with  carmin ;  they  are  3  to 


2l6 


THE    PATHOLOGY   OF   THE    EYE 


4/i  broad  (Schirmer).  The  condition  is  easily  reproduced  in  rabbits  by 
inoculation  of  the  cornea  (Leber,  Uhthoffand  Axenfeld).  Colonies  can 
be  obtained  upon  blood-serum,  not  upon  glycerin  agar  or  bouillon 
(Uhthoff  and  Axenfeld).  Gentilini  obtained  profuse  cultures  upon 
glycerin  agar,  as  well  as  upon  potato  and  bread.  They  were  greenish 
in  colour,  and  showed  under  the  microscope  a  richly  branching  myce- 
lium with  many  fructifications.  These  were  club-shaped  on  a  fairly 
long  stalk,  the  conidia  themselves  being  round.  Aspcrgillus  fumigatus 
is  the  only  species  which  has  been  observed  in  the  cornea ;  other  patho- 
genic species  (A.  flavescem,  niger,  mucor,  etc.)  have  not  been  found, 


FIG.  142. — MYCOTIC  KERATITIS.      x  250. 

From  a  photograph  by  Buchanan.  Meridional  section  through  the  sloughing 
area,  showing  the  mycelium  of  the  fungus  as  a  densely  felted  network.  The 
anterior  layer  is  composed  entirely  of  mycelium  (not  of  epithelium),  and  Bowman's 
membrane  is  destroyed. 

though  many  produce  mycotic  keratitis  when  inoculated  into  rabbits' 
corneae  (Leber). 

Schirmer  and  Nobbe  were  able  to  examine  the  whole  eyes.  In 
Schirmer's  case  there  was  an  old  leucoma  adhaerens.  Much  of  the 
cornea  was  ulcerated ;  in  the  middle  of  the  ulcer  the  whole  cornea  was 
pervaded  by  the  mycelium  of  the  fungus.  This  also  spread  back  along 
an  anterior  synechia  into  the  anterior  part  of  the  vitreous.  For  a  large 
area  around  the  network  in  the  cornea  there  were  no  nuclei  stained,  so 
that  the  tissue  was  necrotic.  Beyond  this  was  a  zone  of  dense  round- 
celled  infiltration,  in  every  respect  answering  to  Leber's  infiltration 
ring,  which  is  so  rare  in  other  types  of  hypopyon  ulcer. 

Keratomycosis   aspergillina  does   not   necessarily  give   rise  to  the 


THE    CORNEA  217 

picture  of  hypopyon  keratitis.  In  rare  cases  it  produces  a  simple  infil- 
tration resembling  fascicular  keratitis  (Uhthoff  and  Axenfeld,  Kayser). 
There  is  usually,  however,  the  same  formation  of  a  sequestrum  in 
these  cases. 

LEBER. — A.  f.  O.,  xxv,  2,  1879.  UHTHOFF. — A.  f.  O.,  xxix,  3,  1883.  *  LEBER. — Die 
Entstehung  der  Entziindung,  Leipzig,  1891.  FUCHS. — Wiener  klin.  Woch.,  1894.  UHTHOFF 
AND  AXENFELD. — A.  f.  O.,  xlii,  i,  1896;  xliv,  1897.  SCHIRMER. — A.  f.  O.,  xlii,  i,  1896. 
NOBBE. — A.  f.  O.,  xlv,  3,  1898.  GENTILINI. — B.  z.  A.,  xlv,  1900.  WICHERKIEWICZ. — A.  f.  A., 
xl,  1901.  ROMER. — K.  M.  f.  A.,  xl,  1902.  *  KAYSER,  JOHNSON. — K.  M.  f.  A.,  xli,  1903. 
BUCHANAN. — T.  O.  S.,  xxiii,  1903. 


PERIPHERAL  ANNULAR  INFILTRATION 

Besides  the  ring  infiltration  observed  by  Leber  close  to  a  central 
ulcer  in  rabbits,  and  very  rarely  seen  in  man,  there  is  a  peripheral  ring 


FIG.  143. — PERIPHERAL  ANNULAR  INFILTRATION  OF  THE  CORNEA. 
Treacher  Collins,  Ophth.  Rev.,  xii.     The  thick  line  shows  the  position  of  the 
wound,  the  hatched  ring  that  of  the  infiltration.     The  latter  is  constant  in  position, 
whilst  the  former  varies. 

infiltration,  or  so-called  ring  abscess,  met  with  occasionally  in  perforat- 
ing wounds.  It  has  received  little  attention  in  the  text-books,  being 
only  mentioned  by  Saemisch  and  Vossius. 

The  first  anatomical  examination  was  by  Fuchs,  of  a  case  following 
linear  extraction  in  a  diabetic.  Four  cases  were  later  described  by 
Treacher  Collins  (Fig.  143),  who  considered  the  condition  opposed  to 
Leber's  views  upon  ring  infiltration.  The  peripheral  infiltration  is, 
however,  of  a  totally  different  nature  to  the  central  ring  described  by 
Leber.  One  of  Hertel's  cases  possibly  belongs  to  this  category,  but 
the  subject  has  received  exhaustive  investigation  by  Fuchs  in  a  recent 
paper. 

Peripheral  annular  infiltration  occurs  most  commonly  after  small 
perforating  wounds  caused  by  chips  of  metal ;  it  also  occurs  after 
operations,  having  been  especially  common  in  cataract  extractions  in 
the  pre-antiseptic  days,  and  very  rarely  after  spontaneous  perforation  of 


218 


THE    PATHOLOGY   OF   THE    EYE 


an  ulcer,  and  in  metastatic  ophthalmitis.  It  appears  usually  very  quickly 
after  the  injury;  in  four  cases  one  day,  five  cases  two  days,  three  cases  three 
days,  two  cases  four  days,  one  case  eleven  days  (Fuchs) ;  one  case  eight 
days  (Treacher  Collins).  The  ring  is  at  first  grey,  then  yellow ; 


FIG.  144. — PERIPHERAL  SUPERFICIAL  INFILTRATION  OF  THE  CORNEA. 
Fuchs,  T.   O.    S.,   xxii.      This  type    is    comparatively    innocuous,    ending    in 
absorption  or  the  formation  of  a  shallow  ring  ulcer. 

i'5  mm.  broad,  with  the  peripheral  edge  i — 1*5  mm.  from  the  limbus, 
though  it  may  reach  the  limbus.  The  inner  edge  is  less  clearly  defined 
than  the  outer.  The  edges  of  the  wound  are  usually  little  infiltrated  or 
not  at  all.  The  infiltration  is  invariably  peripheral,  irrespective  of  the 
position  of  the  wound.  The  condition  almost  invariably  goes  on  to 
panophthalmitis. 

When   infiltration  of  the  wound  occurs,  it  occupies  the  posterior 


FIG.  145. — PERIPHERAL  ANNULAR  INFILTRATION  OF  THE  CORNEA,      x  7. 
From  a  specimen  sent  by  Prof.  Fuchs. 

layers  and  does  not  extend  far  peripherally.     Aggregations  of  bacteria 
are  always  found  between  the  lamellae  in  the  same  situation. 

The  peripheral  infiltration  forms  a  ring  concentric  with  the  corneal 
margin,  at  first  I  to  1*5  mm.  from  it,  but  occasionally  farther  in  older 
cases.  It  consists  of  two  zones  :  (i)  amongst  the  middle  and  superficial 


THE    CORNEA 


219 


lamellae,  (2)  immediately  in  front  of  Descemet's  membrane  (Figs.  145, 146). 
The  anterior  infiltration  ring  is  always  most  marked,  the  aggregation  of 
leucocytes  being  often  so  great  that  the  cornea  is  thickened,  the  surface 
projecting  or  even  being  folded.  At  the  periphery  of  the  ring  the 
infiltration  is  greatest  in  the  middle  layers,  the  superficial  layers  being 
more  affected  as  the  centre  of  the  cornea  is  approached.  In  some  cases 
this  is  so  marked  that  the  anterior  ring  is  itself  divided  into  two  zones, 
a  superficial  more  central  one,  and  a  peripheral  deeper  one.  Various 
explanations  may  be  given.  The  superficial  leucocytes  probably  come 
from  the  peripheral  loops  of  the  corneal  blood-vessels,  the  middle  ones 
from  the  anterior  ciliary  vessels.  Possibly  the  emigration  is  earlier  from 
the  limbus  vessels,  so  that  the  leucocytes  have  wandered  farther  into  the 
cornea  ;  or  emigration  may  be  simultaneous,  but  the  resistance  of  the 
lamellae  may  be  greater  in  the  middle  layers ;  or  the  deeper  cells  may 
tend  towards  the  surface  as  they  pass  inwards  (Fuchs).  The  last 
suggestion  seems  to  be  the  least  probable.  Later,  the  infiltration  is  so 


FIG.  146. — PERIPHERAL  ANNULAR  INFILTRATION  OF  THE  CORNEA. 
Fuchs,  T.  O.  S.,  xxii  ;  see  also  A.  f.  O.,  Ivi. 

intense  in  the  superficial  layers  that  necrosis  occurs,  Bowman's  mem- 
brane is  destroyed,  and  the  swelling  disappears,  loss  of  substance  re- 
placing it. 

The  posterior  infiltration  ring  is  less  constant ;  most  of  the  cells  lie 
directly  upon  Descemet's  membrane,  which  is  thus  separated  from  the 
cornea.  The  anterior  and  posterior  rings  are  usually  separated  by  an 
area  of  diffuse  infiltration.  Descemet's  membrane  is  intact  in  this 
situation,  so  that  the  leucocytes  do  not  come  from  the  anterior  chamber, 
but  wander  in  from  the  periphery.  There  is  generally  a  wide  clear  zone 
between  the  infiltration  and  the  periphery,  but  there  is  often  a  separate, 
very  localised  infiltration  at  the  extreme  periphery. 

The  corneal  corpuscles  are  only  stained  well  in  the  anterior  layers ; 
elsewhere  they  are  pale  or  unstained.  Regarding  this  as  evidence  of 
necrosis,  the  cornea  is  most  necrosed  in  the  deepest  layers,  and  for 
a  greater  thickness  near  the  centre ;  the  necrosis  never  reaches  the 
periphery. 

The  epithelium  and  endothelium  are  for  the  most  part  destroyed ; 
Bowman's  and  Descemet's  membranes  mostly  intact.  The  anterior 
chamber  contains  pus  or  fibrinous  coagulum;  elsewhere  there  is  com- 
mencing panophthalmitis. 


22O 


THE    PATHOLOGY   OF   THE    EYE 


Bacteria  were  present  in  large  numbers  in  the  anterior  chamber,  and 
often  in  the  vitreous ;  sometimes  in  the  posterior  layers  at  the  edges  of 
the  wound.  In  the  latter  situation  there  was  often  no  infiltration, 
absence  of  reaction  being  doubtless  due  to  necrosis.  Staphylococci  and 
streptococci  \vere  each  found  twice ;  bacilli  three  times  (twice  in  pure 
culture,  once  mixed  with  cocci). 

Hanke,  working  under  Fuchs,  has  recently  described  a  specific 
bacillus ;  it  was  found  in  pure  culture  in  the  ulcer  and  in  the  hypopyon. 
The  bacilli  are  long  and  thin,  with  rounded  ends,  0*8 — 1*6  n  by  0*3  ju. 
They  are  mostly  extra-cellular,  stain  deeply  with  the  ordinary  aniline 
dyes,  but  are  negative  to  Gram.  They  are  polymorphic  in  pure  cultures, 
varying  from  short  rods  to  whip-like  filaments,  4  /n  and  more  long ;  they 
show  polar  staining  in  old  cultures.  They  do  not  form  spores.  They 
grow  on  all  the  usual  culture  media,  producing  a  green  fluorescence ; 
they  liquefy  gelatine.  They  are  facultative  aerobes,  and  are  motile  in 
hanging  drops.  They  are  virulent  for  mice,  causing  death  within  i — 2 
days  when  injected  intravenously.  Inoculated  into  guinea-pigs'  or 
rabbits'  corneae  they  produce  typical  ring  abscess. 

Fuchs  explains  peripheral  annular  infiltration  (ring  abscess)  of  the 
cornea  thus  :  Bacteria  enter  the  eye,  usually  by  a  perforating  wound, 
multiply  within  it,  and  set  up  purulent  irido-cyclitis  and  a  keratitis  which 
attacks  the  cornea  from  behind.  Ring  infiltration  follows  by  emigration 
of  leucocytes  from  the  peripheral  vessels,  and  is  directed  towards  the 
removal  of  the  necrosed  parts  or  sequestrum.  Rarely  this  is  successful, 
as  in  one  of  the  cases  reported  ;  almost  invariably  it  fails.  This  theory  ex- 
plains the  situation  of  the  necrosis  in  the  cornea  and  the  frequent  absence 
of  infiltration  of  the  edges  of  the  wound,  which  is  never  absent  when 
bacteria  attack  the  cornea  from  the  surface.  The  condition  is  therefore 
quite  different  from  Leber's  central  ring  infiltration,  the  former  being 

directed  against  a  posterior  seques- 
trum and  the  latter  towards  a 
superficial  ulcer. 


SAEMISCH. — In  G.-S.,  iv,  p.  193,  1876. 
Vossius. — Lehrbuch.,  3rd  ed.,  p.  391. 
TREACHER  COLLINS. — Ophth.  Rev.,  xii,  1893. 
HERTEL. — A.  f.  O.,  liii,  2,  1901.  *  FUCHS. — 
A.  f.  O.,  Ivi,  i,  1903.  HANKE. — Z.  f.  A.,  x, 
1903. 

MARGINAL  ULCER 

Various  types  of  marginal  ulcer 
of  the  cornea  have  been  described 
(Fig.  147).  zurNedden  divides  them 
into  two  groups :  (i)  secondary 


FIG.  147. — MARGINAL  ULCER  OF  CORNEA. 
Fuchs,  T.  O.  S.,  xxii.     Epithelium  growing 


over  the  peripheral  edge  of  a  marginal  ulcer,     to    phlyctenular    Conjunctivitis    and 
whilst  the  central  edge  remains  bare  and  in-     blennorrhcea     of    the     conjunctiva  ; 

(2) 


filtrated  with  leucocytes. 


primary  and  independent  of 
conjunctivitis.  The  second  group 
ncludes  (a)  Schmidt-Rimpler's  furrow  keratitis  (v.  infra),  and  perhaps 
Fuchs'  marginal  ulcer  associated  with  the  uric-acid  diathesis,  and 


THE    CORNEA  221 

(6)  those  due  to  a  specific  organism  isolated  by  zur  Nedden.  Two 
types  of  ulcer  are  due  to  this  cause :  (a)  an  isolated  oval,  sickle-  or 
horse-shoe-shaped,  or  ring  ulcer;  (|3)  multiple  punctate  ulcers,  with 
severe  secondary  conjunctivitis.  The  primary  marginal  affections  may 
be  associated  with  hypopyon. 

The  bacillus  is  straight  or  slightly  curved,  0-9  n  long  by  o'6  ju  broad, 
with  rounded  ends ;  it  is  not  stained  by  Gram.  Two  often  lie  end  on' 
like  diplobacilli.  Diagnosis  from  the  Morax-Axenfeld  diplobacillus', 
etc.,  is  only  certain  by  cultural  methods  (v.  p.  47). 

ZL-R  NEDDEX. — A.  f.  O.,  liv,  i,  1902. 

ATHEROMATOUS  ULCER 

Atheromatous  ulcer  (Fuchs),  or  sequestrating  scar-keratitis  (Winter- 
steiner),  occurs  in  old  leucomata  and  anterior  staphylomata. 

The  scars  in  which  these  ulcers  occur  are  nearly  always  the  result  of 
extensive  destruction  of  the  cornea  with  perforation.  They  consist  of 
remnants  of  the  cornea — fragments  of  Bowman's  and  Descemet's 


FIG.  148. — ATHEROMATOUS  ULCER  OF  CORNEA. 

Fuchs,  T.  O.  S.,  xxii ;  see  also  A.  f.  O.(  liii.  Downgrowth  of  epithelium 
beneath  calcareous  plate  in  an  old  leucoma.  The  epithelium  in  front  of  the  plate 
is  necrotic. 

membrane, — and  of  entangled  iris — retinal  pigment  and  fibres  of  the 
sphincter, — bound  together  by  new  connective  tissue.  In  the  early 
stage  they  are  rich  in  vessels ;  these  ultimately  disappear,  and  cal- 
careous particles  are  deposited  in  a  tissue  devoid  of  nuclei.  The  vitality 
of  the  scar  is  reduced  to  a  minimum,  so  that  stagnation  occurs.  The 
deposits  are  at  first  hyaline,  and  are  found  chiefly  upon  the  surface, 
even  in  the  epithelium  ;  they  grow  by  accretion,  and  gradually  become 
impregnated  with  calcium  salts.  There  is  at  first  a  peripheral  zone  of 
fine  particles  ;  later  the  calcareous  masses  are  sharply  limited.  A 
narrow  free  space  next  appears  between  the  mass  and  the  rest  of  the  scar. 

The  nature  of  the  epithelium  is  influenced  by  the  condition  of  the 
scar.  If  the  latter  is  highly  vascular,  the  epithelium  is  thicker  than 
normal ;  it  is  flat  on  the  surface,  but  fills  all  the  inequalities  of  the 
scar,  so  that  it  assumes  a  papillary  form.  Cords  of  epithelium  grow 
down  into  small  and  large  clefts,  and  invade  the  gutter  around  the 
calcareous  plates,  which  they  also  undermine,  leading  at  last  to  the 
formation  of  a  hard  sequestrum  (Fig.  148). 

The  whole  surface  is  often  succulent  and  rich  in  vessels,  like  pannus, 


222  THE    PATHOLOGY    OF   THE    EYE 

covered  by  thickened  epithelium.  This  condition,  however,  is  confined 
in  many  cases  to  the  edges  or  to  islands,  the  main  part  consisting  of 
dense  sclerotic  tissue.  Here  the  epithelium  undergoes  atrophy,  with 
regressive  changes,  such  as  cornification  and  the  formation  of  inter- 
cellular spaces.  There  are  four  ways  in  which  the  epithelium  is 
removed :  (i)  simple  atrophy  and  disappearance,  owing  to  lack  of 
nourishment ;  (2)  cornification  ;  (3)  separation  of  the  cells  by  fluid  and 
the  formation  of  cyst-like  spaces ;  (4)  heaving  up  of  the  epithelium — 
the  so-called  vesicular  and  bullous  keratitis. 

The  growth  of  the  epithelium  under  the  calcareous  plates  helps  the 
invasion  of  the  tissues  by  bacteria,  so  that  inflammation  ensues, 
accompanied  by  extensive  necrosis  throughout  the  whole  thickness  of 
the  scar.  The  infiltration  around  the  mass  is  at  first  in  two  layers,  an 
anterior  and  a  posterior,  which  are  separated  by  a  layer  in  which  the 
necrotic  area  is  in  continuity  with  the  periphery.  It  differs  therefore 
from  an  ordinary  ulcer ;  the  anterior  infiltration  is  probably  directed 
against  the  invading  organisms,  whilst  the  posterior  is  of  the  nature  of 
a  demarcating  infiltration  directed  against  the  necrotic  tissue.  Gradu- 
ally they  meet,  and  the  sequestrum  is  thrown  off.  It  consists  of 
compact  fibrous  tissue,  devoid  of  stained  nuclei,  together  with  pus-cells; 
it  may  or  may  not  contain  calcareous  material.  The  infiltration  around 
the  necrotic  patch  is  cruciform  in  section,  as  in  ulcus  serpens.  It 
differs  from  this,  however,  in  not  progressing  towards  the  periphery. 
Clinically  ulcus  serpens  travels  quickly  over  the  surface  and  gradually 
deepens,  whilst  the  atheromatous  ulcer  scarcely  enlarges  at  all  on  the 
surface,  but  rapidly  deepens,  and  very  often  leads  to  panophthalmitis. 

In  mild  cases  there  is  merely  necrosis  and  elimination  of  a 
superficial,  calcified,  or  otherwise  badly  nourished  layer.  In  severe 
cases  the  suppuration  goes  deeper,  and  invades  the  ciliary  body, 
vitreous,  etc.,  by  way  of  the  adherent  iris,  exactly  as  in  cases  of  late 
infection  described  by  Leber  and  Wagenmann. 

Sections  stained  by  Gram's  method  show  clumps  of  cocci  in  the  puru- 
lent infiltration,  especially  at  the  apex  of  the  wedge,  less  on  the  surface. 

Atheromatous  ulcer  is  characterised,  therefore,  by  necrosis  followed 
by  infiltration,  thus  differing  from  ordinary  ulceration,  in  which  these 
processes  occur  in  the  reverse  order.  It  is  further  allied  to  rare  cases  of 
necrosis  en  masse  of  the  cornea,  such  as  have  been  described  by  Fuchs 
and  Elschnig. 

ARLT. — Lehrbuch.  FUCHS. — A.  f.  O.,  liii,  i,  1901.  DOLGANOFF  AND  SOKOLOFF. — 
A.  f.  A.,  xlvii,  1903.  NECROSIS  EN  MASSE: — FUCHS. — K.  M.  f.  A.,  xviii,  1880.  ELSCHNIG. 
— Wiener  med.  Woch.,  1899. 


MOOREN'S  ULCER 

The  so-called  "  rodent  ulcer "  of  the  cornea,  first  isolated  by 
Mooren  (1867),  is  a  chronic  serpiginous  ulcer  (Nettleship),  which 
develops  from  the  margin  of  the  cornea  and  very  slowly  invades  other 
parts  of  that  structure,  until  finally  the  whole  cornea  may  have 
become  involved.  The  advancing  edge  is  characteristically  under- 


FIG.  149. — MOOREN'S  ULCER,      x   15. 
From  Lister,  R.  L.  O.  H.  Rep.,  xv.     Showing  the  whole  ulcer. 


FIG.  150.— MOOREN'S  ULCER,      x  80. 

From  Lister.  The  overhanging  edge  of  the  ulcer.  The  epithelium  is  very 
irregular  in  thickness,  and  extends  round  the  tip  ;  the  sub-epithelial  tissue  is  infil- 
trated and  vascularised.  The  floor  of  the  ulcer  is  covered  with  broken  down 
corneal  tissue.  On  the  right  a  round  mass  of  epithelium  is  seen. 


224 


THE    PATHOLOGY   OF   THE    EYE 


mined,  as  shown  by  its  grey,  cloudy  appearance,  and  the  fact  that  it 
can  be  lifted  up.  The  ulcer  often  heals  for  a  time,  but  sooner  or  later 
the  symptoms  of  irritation  recur,  and  the  ulcer  pushes  its  way  some- 
what farther  into  the  cornea.  The  healed  part  is  deprived  of  its 
superficial  layers  and  remains  cloudy  ;  perforation  never  occurs. 

Microscopical  examinations  have  been  made  by  Lawford  (1889), 
Krey  (1890),  Hillemanns,  Schmidt-Rimpler,  and  Lister.  Lawford's 
case  was  regarded  at  the  time  as  an  ulcerating  epithelioma.  The 
posterior  layers  of  the  cornea  were  fairly  normal,  showing  merely  some 
increased  nucleation,  and  in  the  peripheral  part  a  few  new  vessels. 
Bowman's  membrane  was  intact  only  over  a  small  area,  probably 
corresponding  with  an  island  which  had  not  ulcerated.  The  floor  of 
the  ulcer  consisted  almost  entirely  of  small  round  cells — a  sort  of 


From  Lister, 
round-cells. 


FIG.  151.  — MOOREN'S  ULCER,      x  80. 
The  outer  edge   of  the  ulcer,  showing  great  infiltration   with 


granulation  tissue  ;    here  and  immediately  subjacent  were  numerous 
small  blood-vessels. 

The  ulcer  usually  destroys  about  one  third  of  the  thickness  of  the 
cornea.  The  granulation  tissue  which  is  seen  forming  the  floor  of  the 
active  ulcer  is  thicker  and  more  organised  in  the  healed  part.  Here 
the  total  thickness  of  the  cornea  may  exceed  the  normal.  It  is  covered 
by  much  thickened  epithelium,  which  has  a  very  irregular  base  line, 
downgrowths  often  passing  in  various  directions.  Beneath  this  is  the 
scar  tissue,  which  is  highly  vascular  and  infiltrated  with  lymphocytes 
in  the  earlier  stages,  and  consists  of  clear,  fine  fibrillae  in  the  older. 
This  layer  diminishes  in  thickness  from  the  limbus  towards  the  ulcer. 
Beneath  it  are  the  corneal  lamellae;  Descemet's  membrane  and  the 
endothelium  are  normal.  At  the  periphery  Hillemanns  found  some 
branches  of  the  anterior  ciliary  arteries  containing  hyaline  thrombi. 


THE    CORNEA  225 

The  overhanging  edge  at  the  advancing  border  of  the  ulcer  usually 
consists  not  only  of  epithelium,  but  also  of  a  varying  number  of  corneal 
lamellae,  usually  about  one  third  the  thickness  of  the  cornea  (Fig.  150). 
These  are  infiltrated  and  undergoing  necrosis.  Near  this  edge  there 
are  blood-vessels  between  the  lamellae  ;  beyond  it,  Bowman's  membrane 
is  destroyed  for  a  short  distance. 

The  ulcers  have  been  examined  for  micro-organisms,  and  Andrade 
has  described  a  specific  bacillus.  The  bacilli  are  small  mobile  rods, 
sometimes  lying  side  by  side,  sometimes  grouped  as  diplobacilli,  or 
forming  long  chains.  They  are  coloured  by  Gram's  method,  and 
liquefy  gelatine  and  Loffler's  blood-serum.  They  grow  with  difficulty 
on  agar  ;  they  do  not  produce  indol ;  they  require  oxygen  to  grow  well. 
I  have  taken  cultures  from  several  cases  of  Mooren's  ulcer,  but  have 
failed  to  obtain  Andrade's  or  any  other  specific  organism. 

MOOREN. — Ophthalmiatrische  Beobachtungen,  1867;  Ophthalmologische  Mittheilungen, 
1873.  LAWFORD. — R.  L.  O.  H.  Rep.,  xii,  3,  1889.  KREY. — Inaug.  Diss.,  Kiel,  1890.  HILLE- 
MANNS.— A.  f.  A.,  xl,  1899.  ScHMiDT-RiMPLER. — A.  f.  A.,  xxxviii,  1899;  A.  of  O.,  xxx, 
1901.  ANDRADE. — Ann.  di  Ott,  xxix,  1900.  *  NETTLESHIP. — T.  O.  S.,  xxii,  1902.  LISTER. 
— R.  L.  O.  H.  Rep.,  xv,  1903. 


DEGENERATIONS 

DEGENERATIVE  CHANGES  IN  THE  EPITHELIUM 

We  have  already  considered  the  degenerative  changes  which  occur 
in  the  epithelium  from  redema  (p.  175),  from  the  improper  use  of 
cocain  (p.  203),  in  various  types  of  pannus  (p.  194),  etc.  There  are  a 
few  other  conditions  which  require  consideration,  more  particularly 
those  resulting  from  malnutrition  and  desiccation. 

There  may  be  little  change  in  the  epithelium  over  a  primary  focus 
of  infiltration  (Fig.  152). 

Insufficient  nutrition  may  lead  to  atrophy  of  the  epithelium, 
manifesting  itself  by  diminution  of  the  number  and  size  of  the  cells. 
The  superficial  flat-cells  lose  their  nuclei  and  become  thin  scales,  the 
middle  polygonal  cells  are  changed  into  flat  ones,  which  lie  immediately 
upon  the  cylindrical  foot-cells  (Fig.  153).  Later  on  these  too  become 
shorter,  oblique,  and  finally  flat  (Figs.  154, 155),  and  in  the  highest  degree 
of  atrophy  the  epithelium  fades  gradually  away  (Figs.  153, 155).  Thinning 
by  atrophy  is  most  seen  in  cicatricial  conditions  of  the  cornea,  especially 
when  combined  with  calcareous  deposits.  The  scar  tissue  has  probably 
increased  resistance  to  the  invasion  of  organisms,  owing  to  the  absence 
of  lymph-channels  and  the  occasional  presence  of  blood-vessels.  This 
is  not  sufficient  to  protect  the  tissues  invariably,  as  is  shown  by  the 
occurrence  of  atheromatous  ulcers  (v.  p.  221).  Malnutrition  causing 
atrophy  may  be  due  to  local  causes,  e.  g.  tuberculosis  of  the  iris  and 
ciliary  body  (Fig.  154),  or  to  general  causes,  e.g.  in  keratomalacia. 

Circumscribed  necrosis  of  the  epithelium  may  occur  in  an  otherwise 
normal  cornea  after  irritation  (Fuchs).  After  cataract  extraction 
minute  grey  spots  may  sometimes  be  seen  in  the  cornea  near  the 

15 


1  ^"1^     *^   t^^^jti  •— 


FIG.  152. — PRIMARY  KERATITIS. 

Fuchs,  T.  O.  S.,  xxii.  Comparative  freedom  from  change  of  the  epithelium  in 
primary  keratitis.  Bowman's  membrane  is  infiltrated  and  destroyed  in  the  centre 
of  the  figure. 


FIG.  153. — ATROPHY  OF  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xxii.  Thinning  off  of  the  epithelium,  with  diminution  in  the 
number  of  the  cells,  and  formation  of  thin  scales,  devoid  of  nuclei.  The  basal  cells 
become  shorter  and  oblique. 


^ 


FIG.  154. — ATROPHY  OF  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xxii.  From  a  case  of  tubercle  of  the  iris  and  ciliary  body 
in  a  child.  The  basal  cells  have  become  quite  flat  and  are  directed  horizontally. 
Bowman's  membrane  is  intact.  The  superficial  lamella;  are  swollen  and  jelly-like, 
with  an  increased  number  of  nuclei. 


FIG.  155. — ATROPHY  OF  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xxii.     From  near  the  margin  of  a  corneal  infiltration, 
epithelium  thins  off  and  disappears.     Bowman's  membrane  is  intact. 


The 


FIG.  156. — ATROPHY  AND  NECROSIS  OF  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xx'n.  The  superficial  layers  are  necrotic,  being  changed  into 
a  nearly  homogeneous  mass,  devoid  of  nuclei.  Such  appearances  are  found  near 
corneal  ulcers. 


FIG.  157. — INFILTRATION  OF  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xx'u.     Infiltration  of  a  localised  spot  of  epithelium  with  round- 
cells,  Bowman's  membrane  and  the  subjacent  cornea  being  intact. 


FIG.  158. — DESICCATION  OF  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xxii.     Margin  of  uncovered  cornea  in  lagophthalmos.      (For 
explanation,  see  Text.) 


FIG.  159. — TOTAL  EXFOLIATION  OF  EPITHELIUM. 

Fuchs,  T.  O.  S.,  xxii.  From  a  case  of  commencing  panophthalmitis.  Total 
exfoliation  of  epithelium  and  endothelium  ;  necrosis  of  substantia  propria,  as  shown 
by  absence  of  stained  nuclei. 


228  THE    PATHOLOGY   OF   THE    EYE 

margin,  especially  near  the  incision.  They  may  develop  to  very  small 
ulcers,  but  generally  disappear  in  a  day  or  two.  They  are  probably 
small  foci  of  epithelial  necrosis  due  to  the  action  of  cocain,  sublimate, 
etc.  A  small  opaque  spot  may  also  correspond  with  an  inflammatory 
infiltration  with  lymph-cells,  limited  entirely  to  the  epithelium  (Fig.  157). 

Fig.  158  shows  the  effect  of  drying.  In  a  the  desiccation  affects 
only  the  superficial  layers.  If  the  basement-cells  resist,  the  epithelium 
will  be  preserved  ;  the  superficial  cells  will  lose  their  nuclei,  or  become 
keratinised  (v.  p.  170),  whilst  the  basement-cells,  in  consequence  of  the 
irritation,  will  increase  their  proliferating  activity,  and  the  epithelium 
will  become  thickened.  If  the  desiccation  goes  deeper,  as  in  b,  the 
basal  cells  are  also  destroyed,  and  will  be  thrown  off. 

After  prolonged  exposure  the  epithelium  becomes  epidermoid  in 
type,  exactly  resembling  that  of  the  skin.  This  occurs  in  the  cornea 
in  anterior  staphyloma  (p.  170),  as  well  as  in  the  conjunctiva  in  xerosis, 
etc.  (p.  103). 

Finally  the  whole  epithelial  covering  of  the  cornea  may  be  cast  off. 
This  takes  place  typically  in  neuro-paralytic  keratitis.  It  is  also  found 
in  acute  disease  affecting  the  eye  as  a  whole,  e.  g.  panophthalmitis.  Here 
the  desquamation  is  part  of  a  more  extensive  process  involving  the 
whole  cornea.  In  Fig.  159  the  posterior  endothelium  has  been 
destroyed,  and  more  than  two-thirds  of  the  substantia  propria  exhibit 
not  a  single  stained  nucleus,  proving  thus  their  complete  necrosis. 
Only  in  the  anterior  still  living  layers  of  the  cornea  an  infiltration  has 
taken  place,  and  the  epithelium  has  been  thrown  off  entirely.  Similar 
changes  are  found  in  other  cases  of  partial  or  complete  necrosis, 
e.  g.  ring  infiltration  (q.  v.),  necrosis  en  masse  (q.  v.),  etc.  The 
damaging  of  the  epithelium  by  the  influence  of  the  aqueous  humour 
may  become  manifest  also  in  slighter  cases,  where  in  the  cornea  itself 
no  disturbance  may  be  manifest. 

FUCHS. — T.  O.  S.,  xxii,  1902. 

HYALINE  DEPOSITS  (DRUSEN)  ON  BOWMAN'S  MEMBRANE 

Bowman's  membrane,  being  a  specially  differentiated  part  of  the 
substantia  propria,  is  not  a  hyaline  membrane  derived  from  epithelial  or 
endothelial  cells.  Very  rarely  hyaline  deposits  are  seen  upon  it, 
resembling  those  which  occur  upon  Descemet's  and  Bruch's  mem- 
branes. 

They  were  first  described  by  Rindfleisch  (1891)  as  swollen,  greyish, 
transparent  spots  in  a  congenitally  defective  eye.  Bowman's  mem- 
brane in  the  middle  of  the  cornea  was  scarcely  distinguishable  from  the 
hyaline  substantia  propria;  on  its  surface  were  several  small  hemi- 
spherical thickenings,  uniting  with  it  and  staining  in  the  same  manner. 

Leber  (1897)  described  nodules  on  Bowman's  membrane  in  band 
keratitis  (q.  v.).  These  are  identical  with  the  hyaline  deposits  found  in 
"colloid"  degeneration  (q.  v.),  and  are  different  from  the  typical 
hyaline  deposits  which  are  confined  to  Bowman's  membrane. 

Only  one  quite  typical  case  has  been  described,  viz.  by  Elschnig 


THE    CORNEA  229 

(1899).  The  deposits  occurred  in  the  almost  normal  eye  of  a  man  with 
chronic  lead-poisoning,  and  were  detected  by  the  irregular  refraction  of 
the  surface  of  the  cornea.  By  oblique  illumination  irregular  reflexes 
were  seen,  as  if  caused  by  globular  drops  of  different  refrangibility  from 
the  surrounding  media.  Microscopically  there  were  rows  of  smooth, 
hemispherical,  homogeneous  deposits  on  the  surface  of  Bowman's 
membrane.  The  epithelium  over  them  was  thinned  at  the  summit,  so 
that  the  surface  of  the  epithelium  remained  smooth.  The  smallest 
"  Drusen  "  were  less  than  the  thickness  of  Bowman's  membrane,  whilst 
the  largest  were  somewhat  laminated,  and  were  two  to  two  and  a  half 
times  as  thick.  The  larger  the  deposits  the  more  sharply  they  were 
denned,  a  small  cleft  being  visible  below  some  of  them.  With 
hsematoxylin  and  eosin  they  stained  deeper  than  Bowman's  membrane, 
with  van  Gieson  a  paler  yellow,  paler  blue  with  thionin,  deeper  with 
saffranin,  nigrosin,  and  Weigert's  elastic-tissue  stain  ;  they  remained 
unstained  with  iodine,  acid  orcein  (Unna-Tanzer),  and  Meyer's  muc- 
haematein.  They  are  therefore  not  amyloid,  but  must  be  relegated  to 
the  indeterminate  hyaline  deposits.  Elschnig  regards  them  as  products 
of  the  epithelium,  the  main  argument  against  this  view  being  the 
nature  and  origin  of  Bowman's  membrane.  In  all  probability  Bowman's 
membrane  has  nothing  to  do  with  their  actual  development ;  they 
merely  lie  upon  it.  It  is  quite  possible  that  they  may  be  degeneration 
products  of  exudates,  which  are  not  infrequently  found  in  this 
situation,  and  the  general  condition  of  the  patient  (lead-poisoning)  is 
rather  in  favour  of  this  view  than  of  an  epithelial  origin. 

RINDFLEISCH. — A.  f.  O.,  xxxvii,  3,  1891.      LEBER. — B.  d.  o.  G.,  1897.      *  ELSCHNMG. — 
K.  M.  f.  A.,  xxxvii,  1899. 


HYALINE  DEPOSITS  (DRUSEN)  ON  DESCEMET'S  MEMBRANE 

It  has  already  been  mentioned  that  Descemet's  membrane  increases 
in  thickness  with  age.  Localised  hemispherical  thickenings,  protruding 
upon  the  posterior  surface,  are  not  uncommon,  and  were  first  described 
by  Hassall  and  Henle.  They  commence  at  the  periphery,  usually  at 
about  twenty  to  thirty  years  of  age,  and  are  always  most  marked  here. 
They  project  3 — 5  /j.  above  the  surface,  forming  two  to  four  incomplete 
rows,  which  increase  in  number  later  in  life,  and  may  rarely  involve 
the  whole  area,  seldom  projecting  more  than  10 — 12  /m.  They  may 
thus  become  visible  macroscopically,  and  may  be  mistaken  for  punctate 
opacities.  Like  the  membrane  itself  they  are  the  products  of  secretion 
of  the  endothelial  cells  (Leber),  and  are  in  all  respects  comparable  with 
the  "  colloid  "  bodies  of  the  choroid,  and  may,  like  them,  become 
calcified.  The  endothelial  cells  usually  remain  in  the  depressions 
between  the  excrescences,  forming  star-shaped  figures.  Care  must  be 
taken  not  to  confound  oblique  sections  of  Descemet's  membrane, 
artefacts  from  inefficient  hardening,  etc.,  with  these  new  formations. 

HASSALL. — The  Microscopic  Anatomy  of  the  Human  Body.  HENLE. — Handbuch  der 
syst.  Anat.,  ii,  1866.  LEBER. — A.  f.  O.,  xxv,  3,  1879.  WALDEYER. — In  G.-S.,  i,  1874;  and 
in  de  Wecker  and  Landolt's  Traite,  ii,  1886. 


230 


THE    PATHOLOGY   OF   THE    EYE 


ARCUS  SENILIS 

Very  various  opinions  have  been  expressed  from  time  to  time  as  to 
the  pathological  changes  in  the  cornea  in  arcus  senilis. 

Canton  first  accurately  described  the  microscopic  appearances. 
His  careful  description  (well  illustrated  in  his  book)  is  as  follows: — 
"  With  a  power  of  200  diameters  we  shall  observe  myriads  of  fine  oil- 
globules  in  the  situation  of,  and  constituting  the  arcus.  Many  larger 
globules  are  present,  and  this  magnitude  has  doubtless  been  attained  by 
the  coalescence  of  the  smaller  spherules.  We  notice  also  that  the  oil- 
drops  are  arranged  in  two  ways: — First,  in  the  direction  of  such  of  the 


FIG.  160.— ARCUS  SENILIS.      x  55. 

Stained  by  hsematoxylin  and  Scharlach  R.     Note  the  distribution  of  the  fatty 
globules  (see  Text). 

lamellae  as  have  disappeared,  and  which  they  replace — a  fatty  degene- 
ration or  conversion,  and  second,  in  the  interstices,  or  between  the 
lamellae — a  fatty  deposition.  The  slight  elevation  which  the  cornea 
presents  at  the  site  of  the  arcus  is  due  to  this  latter  condition. 

"  At  the  commencement  of  these  changes  the  oil-drops  will  be  found 
in  the  corneal  cells,  and  often,  too,  are  present  in  the  fine  branches  or 
processes  prolonged  from  these  cells ;  in  the  same  manner  as  the 
contents  of  the  cellular  elements  of  other  organs  are,  primarily,  affected 
where  fatty  degeneration  occurs,  and  where,  in  the  further  progress  of 
the  affection,  we  may  notice  also  the  intercellular  deposit."  .... 

"  I  have  never  seen  Bowman's  membrane  (anterior  elastic  lamina) 
nor  that  of  Descemet  (posterior  elastic  lamina)  to  be  otherwise  than 
unaltered."  .... 


THE    CORNEA  231 

"  With  respect  to  the  rim  of  cornea  lying  just  external  to  the  true 
arcus,  and  which,  as  a  general  rule,  is  unaffected,  it  will  be  not  unfre- 
quently  found,  in  instances  where  an  arcus  is  very  broad,  or  a  dense 
circle  exists,  that  this  part  has  become  implicated  also  to  a  greater 
or  less  degree  by  a  continuity  of  fatty  degeneration  from  the  arcus 
itself.  This  occurs  more  commonly  above  and  below,  than  at  the  sides 
of  the  cornea."  .... 

"  I  have  in  some  cases  found  the  fatty  degeneration  to  extend  com- 
pletely into  the  line  of  junction  of  cornea  and  sclerotic  ;  and  have  occa- 
sionally seen  the  interstices  of  the  sclerotic  fibres  as  they  are  becoming 
corneal  laminae,  in  many  places,  loaded  with  oil-drops." 

His  says  :  "  If  thin  sections  through  an  arcus  senilis  are  examined, 
the  fat  is  principally  found  to  consist  of  extremely  fine  globules,  which 
are  arranged  in  thickly  set  parallel  thread-like  rows.  These  parallel 
rows  cross  in  various  directions  and  so  form  a  kind  of  thick  network, 
which,  when  it  is  many  layers  thick,  causes  considerable  opacity  in  the 
tissue.  In  some  places  large  groups  of  globules  are  collected,  in  the 
midst  of  which  one  or  more  stunted  rudiments  of  a  nucleus  may  occa- 
sionally be  seen.  These  fat-drops  have  no  capsule,  and  it  is  impos- 
sible to  prove  from  their  appearance  only  that  they  correspond  to  a 
degenerated  corneal  corpuscle.  On  the  other  hand,  there  are  un- 
doubtedly corneal  cells  with  more  or  less  fat  within  them,  especially  in 
the  more  posterior  layers  and  in  the  parts  where  the  opacity  is  less  in- 
tense. Such  cells  are  not  actually  enlarged,  and  the  fat  lies  partly  in 
the  cell-body  and  partly  in  the  fine  processes  and  their  ramifications." 

Virchow  used  the  arcus  senilis  as  a  typical  example  of  parenchy- 
matous  changes.  He  considered  it  a  fatty  degeneration  of  the  corneal 
tissue,  and  due  to  deposition  of  fat  in  the  cells  themselves. 

Fuchs,  in  a  paper  on  pinguecula,  says  :  "  Concretions  of  the  same 
nature  as  those  found  in  pinguecula  constitute  the  opacity  of  the 
cornea,  which  is  called  arcus  senilis.  Senescence  of  tissue  leads  there- 
fore in  the  cornea  to  the  same  results  as  in  the  conjunctiva.  .  .  . 
The  greenish-coloured  round  concretions  which  form  it  lie  for  the  most 
part  immediately  under  Bowman's  membrane.  They  consist  of  various 
sizes,  from  the  smallest,  scarcely  visible  up  to  0*03  mm.,  mostly  arranged 
in  a  single  layer  under  Bowman's  membrane.  The  larger  concretions, 
by  pressure  on  the  posterior  surface  of  Bowman's  membrane,  dig  as  it 
were  niches  in  it,  the  largest  thin  the  membrane  very  markedly  and 
push  it  forwards.  The  concretions  do  not  occur,  however,  only  under 
Bowman's  membrane  ;  there  are  some  which  lie  considerably  deeper, 
between  the  corneal  lamellae.  In  some  cases,  indeed,  I  have  only 
found  large  groups  of  concretions  here,  whilst  there  were  none  present 
immediately  under  Bowman's  membrane.  On  the  other  hand,  there 
are  concretions  which  are  found  within  Bowman's  membrane  itself  or 
even  upon  it.  In  the  first  case,  when  the  concretions  are  very  fine, 
the  membrane  appears  as  if  dusted  over,  but  it  may  also  contain  larger 
concretions.  In  the  second  case  the  concretions  are  embedded  between 
the  cells  of  the  corneal  epithelium.  There  is  never  any  relation  to  be 
perceived  between  the  concretions  and  the  cells  of  the  corneal  tissue ; 
the  hyaline  substance  is  here,  exactly  like  the  yellow  masses  in  pingue- 


232  THE    PATHOLOGY    OF   THE    EYE 

cula,  lying  separated  and  free  upon  the  surface  of  the  connective-tissue 
bundles  (here  corneal  lamellae).  The  concretions  in  the  cornea  give  the 
same  reactions  as  the  concretions  in  pinguecula.  I  may  here  only 
further  state  that  they  undergo  no  change  whatever  with  ether  or 
chloroform,  so  that  therefore  they  are  certainly  not  fat,  as  generally 
held." 

Leber  is  of  opinion  that  in  arcus  senilis  there  is  a  combination  of 
hyaline  degeneration  with  a  deposition  of  calcareous  material.  In 
one  case  he  obtained  the  very  definite  calcium  reaction  with  oxalic  acid. 

Tweedy  writes:  "  According  to  some  investigations  made  by  the 
writer  in  conjunction  with  Mr.  E.  T.  Collins,  in  the  laboratory  of 
Moorfields  Eye  Hospital,  the  change  in  the  cornea  consists  in  the 
presence  of  fine,  highly  refractive  molecules,  distributed  along  the 
course  of  the  lymphatic  spaces  and  channels  of  the  superficial  layers  of 
the  periphery  of  the  cornea  near  the  loop-endings  of  the  capillaries  of 
the  conjunctival  and  episcleral  blood-vessels.  The  greater  portion  of 
these  molecules  are  not  fatty,  as  is  generally  supposed  ;  for,  unlike  fat, 
they  are  neither  blackened  by  osmic  acid  nor  dissolved  by  ether.  They 
probably  arise  from  mucoid  degeneration  of  the  protoplasm  within  the 
lymphatic  channels  and  spaces  of  the  cornea,  and  to  some  extent  of 
the  fibrillae  themselves.  A  few  doubtful,  blackened,  fatty  molecules 
may  be  seen  here  and  there  in  sections  stained  by  osmic  acid.  The 
fibrillae  are  slightly  wrinkled,  and  are  more  loosely  held  together  than 
natural,  and  the  spaces  between  the  laminae  are  wider.  In  support  of 
the  non-fatty  nature  of  arcus  senilis,  it  may  be  stated  that  wounds  of 
the  cornea,  whether  through  the  opacity,  or  to  its  inner  side,  or  to  its 
outer,  and  whether  surgical  or  traumatic,  heal  in  a  natural  way." 

Takayasu,  working  in  Greeff  s  laboratory,  used  Sudan  III  as  a  test 
for  fat,  and  arrived  definitely  at  the  conclusion  that  arcus  senilis  is  a 
fatty  degeneration. 

In  my  own  experiments  I  have  used  Sudan  III  and  an  allied  stain, 
Scharlach  R.  The  results  confirm  the  description  of  Takayasu,  and  I 
have  extended  the  observations  by  employing  the  stains  as  chemical 
indicators  of  the  presence  or  absence  of  the  arcus  after  the  action  of 
various  reagents. 

When  stained  with  either  of  the  dyes,  the  smaller  globules  are 
coloured  reddish  yellow,  the  larger  ones  deep  orange.  With  Scharlach  R 
the  stain  has  a  brick-red  tinge.  The  eyes  were  hardened  in  formol,  the 
corneae,  including  the  iris  and  ciliary  body,  being  then  removed  by  a 
circular  incision  through  the  sclerotic  2  or  3  mm.  behind  the  corneo- 
scleral  margin.  The  corneae  were  then  divided  into  quadrants,  washed  in 
running  water  to  remove  the  formol,  immersed  in  gum  until  penetrated, 
and  cut  with  the  freezing  microtome.  After  being  freed  from  gum  by  warm 
water,  sections  were  placed  in  saturated  solutions  of  the  stain  in  70  per 
cent,  alcohol.  Stronger  solutions  of  alcohol  dissolve  out  the  globules.  In 
Sudan  III  the  sections  are  well  stained  in  from  ten  to  fifteen  minutes ; 
longer  treatment  leads  to  slight  diffuse  staining  of  the  corneal  tissues, 
but  this  is  washed  out  in  subsequent  treatment  with  70  per  cent, 
alcohol.  It  is  possibly  due  to  a  fatty  moiety  in  more  stable  combination 
in  the  normal  tissues,  for  traces  of  fatty  material  can  be  extracted  from 


THE   CORNEA  233 

almost  every  tissue  of  the  body.  Scharlach  R  stains  more  slowly,  but 
does  not  tend  to  diffuse  staining,  even  after  prolonged  (twenty-four 
hours  or  more)  treatment,  and  is  therefore  a  more  reliable  test  of 
differentiation.  The  sections  after  staining  are  washed  rapidly  in 
70  per  cent  alcohol,  a  more  prolonged  differentiation  being  required  in 
sections  over-stained  by  Sudan  III.  They  are  then  washed  in  water, 
and  counter-stained  with  Meyer's  haemalum  or  Ehrlich's  haematoxylin. 
This  stains  the  nuclei  of  the  corneal  corpuscles,  etc.,  and  to  some 
extent  delimits  the  corneal  fibres.  Haemalum  is  preferable,  as  it  is  a 
pure  nuclear  stain ;  it  may  precede  the  treatment  with  the  fat  stain. 
The  sections  are  then  treated  with  tap-water  until  the  haematoxylin  is 
a  satisfactory  violet,  and  are  mounted  in  glycerin. 

In  sections  so  treated,  globules  of  varying  size  are  seen  to  pervade 
Bowman's  membrane  and  the  corneal  lamellae  in  the  affected  area. 
(Fig.  160).  Those  in  Bowman's  membrane  are  usually  the  smallest, 
so  small,  indeed,  that  a  general  diffuse  granular  stain  is  all  that  is  seen 
without  the  assistance  of  an  oil-immersion  objective.  A  few  minute, 
isolated,  well-defined  gloubles  may  be  seen  in  some  cases.  The  stain 
is  densest  at  the  termination  of  Bowman's  membrane,  and  this  is  the 
cause  of  the  very  definite  peripheral  edge  of  the  arcus,  as  seen  clinically. 
Bowman's  membrane  ends  at  an  appreciable  distance  from  the  apparent 
corneo-scleral  margin,  and  this  distance  is  occupied  by  the  clearer 
cornea,  which  is  characteristic  of  arcus  senilis.  That  it  is  not  in  reality 
as  clear  as  the  centre  wrill  be  evident  from  subsequent  remarks. 
Towards  the  centre  of  the  cornea  the  stain  in  Bowman's  membrane 
very  gradually  fades  off,  the  distance  varying  with  the  development  of 
the  arcus  in  the  particular  cornea.  It  always,  however,  extends  farther 
centrally  than  the  stain  in  the  substantia  propria. 

In  the  substantia  propria  the  globules  are  limited  to  the  lamellae 
and  corneal  corpuscles,  and  are  not  contained  in  the  lymphatic  spaces 
and  channels.  The  droplets  are  usually  larger  than  those  in  Bowman's 
membrane,  but  the  finer  punctate  appearance  is  seen  around  the  larger 
drops.  The  largest  drops  are  from  5 — 10  p  in  length,  and  about  half 
the  width,  the  long  axis  being  in  the  direction  of  the  lamellae,  i.  e.  more 
or  less  concentric  with  the  surface  of  the  cornea.  This  is  due  doubtless 
to  the  conditions  of  tension  of  the  tissues.  The  smaller  globules  also 
show  a  similar  disposition  to  be  arranged  in  layers  in  the  same 
direction  ;  they  are  invariably  punctate  or  spherical. 

Tangential  sections  demonstrate  that  minute  drops  are  also  con- 
tained in  the  cytoplasm  of  the  corneal  corpuscles,  extending  into  the 
processes  of  the  cells,  and  showing  a  polar  arrangement  near  the 
nucleus,  as  pointed  out  by  His  and  Virchow. 

Immediately  beneath  Bowman's  membrane  the  stain  is  limited  to 
the  same  extent,  but  each  succeeding  lamella  is  affected  a  little  farther 
towards  the  periphery,  so  that  in  transverse  sections  a  kind  of  staircase 
arrangement  is  seen.  The  deeper  layers  are  usually  less  affected 
towards  the  centre  of  the  cornea,  and  the  density  of  the  deposit  also 
diminishes  from  before  backwards,  so  that  the  middle  layers  of  the 
substantia  propria  are  little  stained  or  not  at  all.  Even  under  these 
circumstances,  however,  there  is  a  further  increase  in  the  deepest 


234  THE    PATHOLOGY    OF   THE    EYE 

layers,  but  the  stain  is  not  distributed  here  so  uniformly,  with  the 
single  exception  that  it  is  invariably  extremely  dense  upon  the  surface 
of  Descemet's  membrane.  With  a  low  power,  and  particularly  in  thick 
sections,  Descemet's  membrane  seems  to  be  much  involved,  but  with  a 
higher  power,  and  in  thin  sections,  it  is  obvious  that  it  escapes  entirely 
in  reality,  the  dense  deposit  being  only  upon  the  anterior  surface. 

It  is  therefore  obvious  that  the  clearer  peripheral  ring  of  cornea  is 
not  entirely  unaffected,  but  is  comparatively  clear,  owing  to  the  absence 
of  Bowman's  membrane  and  the  slighter  implication  of  the  more  super- 
ficial layers  of  the  substantia  propria  due  to  the  staircase  arrangement. 

Beyond  the  true  corneal  margin  there  is  a  limiting  area  of  sclerotic 
which  I  have  never  seen  affected.  Beyond  this,  however,  there  is 
frequently  some  deposition  of  fatty  material  in  the  deeper  layers  of  the 
sclerotic. 

Slight  deposition  of  fat  is  almost  invariably  seen  in  the  roots  of  the 
ciliary  processes.  This  is  probably  physiological. 

Using  Sudan  III  or  Scharlach  R  as  indicators,  it  is  found  that  the 
material  is  insoluble  in  water,  dilute  acetic  acid,  Miiller's,  Marchi's, 
Flemming's,  and  Hermann's  solutions,  etc.,  and  that  it  is  soluble  in 
absolute  alcohol,  ether,  chloroform,  xylol,  etc.  Thus,  after  staining 
with  Sudan  III  and  immersion  for  half  a  minute  in  absolute  alcohol, 
scarcely  a  trace  of  the  stain  remained,  no  globules  could  be  seen,  and 
the  lamellae  had  the  appearance  of  normal  lamellae.  Similar  treatment 
for  half  a  minute  in  ether  resulted  in  total  disappearance  of  the  stain 
and  the  arcus.  Hence  arcus  senilis  cannot  be  demonstrated  in  paraffin 
or  celloidin  sections. 

The  globules  can  be  dissolved  out  and  restained  upon  the  slide. 
Thus,  a  section  was  stained  with  Sudan  III  and  mounted  in  70  per 
cent,  alcohol,  covered  with  a  cover-glass,  and  watched  under  the 
microscope.  A  small  quantity  of  absolute  alcohol  was  placed  upon 
one  side  of  the  cover-glass  and  drawn  through  by  means  of  blotting- 
paper.  This  was  followed  by  a  small  dose  of  ether.  The  stain  was 
rapidly  dissolved  out.  The  section  was  then  restained  with  Sudan  III 
upon  the  slide,  the  ether  having  evaporated.  Many  oil-globules  were 
seen  hanging  about  the  anterior  surface  of  the  epithelium,  well  stained 
by  the  dye. 

Fresh  sections  were  stained  by  various  solutions  containing  osmic 
acid,  for  varying  lengths  of  time.  No  definite  staining  was  obtained 
with  2  per  cent,  osmic  acid,  unless  it  was  allowed  to  gradually  dry,  in 
which  case  the  whole  section  became  black.  It  is  known  that  osmic 
acid  acts  best  after  previous  treatment  of  the  sections  with  hardening 
reagents — 2  per  cent,  osmic  acid,  after  treatment  of  the  section  with 
70  per  cent,  alcohol,  failed  to  stain  the  deposit.  Sections  were  placed 
in  large  quantities  of  Marchi's  solution,  Flemming's  solution,  and 
Hermann's  solution,  and  examined  at  intervals  from  twenty-four  hours 
to  three  weeks,  being  mounted  in  glycerin.  In  no  case  was  there  any 
true  reduction  of  the  osmic  acid.  The  neighbourhood  of  the  arcus 
certainly  showed  a  blackish  appearance,  but  this  was  apparently  due 
to  a  difference  in  the  relative  refractility  of  the  globules  and  the 
surrounding  tissues,  for  under  a  high  power  it  was  seen  that  the  black- 


THE    CORNEA  235 

ness  disappeared  on  slight  alterations  of  focus.  Further,  after  such 
treatment  the  arcus  readily  dissolved  out  when  treated  with  ether, 
leaving  no  trace  behind ;  and  the  blackened  sections,  when  mounted 
in  Canada  balsam  in  the  usual  manner,  could  not  have  been  distin- 
guished from  normal  cornese.  There  can  therefore  have  been  no  true 
reduction  of  the  osmic  acid. 

Fresh  sections  were  treated  by  Bolton's  modification  of  the  Weigert- 
Pal  method ; l  i.e  they  were  placed  in  i  per  cent,  osmic  acid  for  a 
few  minutes,  then  in  ammonium  molybdate  solution  overnight,  stained 
black  with  Kultschitzky's  haematoxylin,  and  differentiated  in  Pal's 
solution.  By  this  means  the  arcus  was  stained  black.  The  stain  was 
removed  on  treatment  with  ether. 

Experiments  were  made  to  see  if  the  globules  contained  phosphorus. 
For  this  purpose,  Macallum's  very  accurate  modification  of  Lilienfeld 
and  Monti's  method  was  used.-  Sections  were  immersed  in  ammonium 
molybdate  solution  for  twenty-four  hours  in  an  incubator  at  35°  C.  ; 
they  were  then  dipped  in  4  per  cent,  solution  of  phenylhydrazin  hydro- 
chloride,  washed  in  water,  stained  in  Sudan  III,  and  mounted  in 
glycerin.  The  distribution  of  phosphorus  in  the  tissues  was  admirably 
shown.  The  arcus  showed  no  trace,  but  was  well  stained  by  the 
Sudan  III.  Sections  similarly  treated,  but  not  counterstained  with 
Sudan  III,  also  showed  the  absence  of  phosphorus  from  the  globules. 

On  the  hypothesis  that  the  material  was  fatty,  an  attempt  was 
made  to  saponify  the  fat  upon  the  slide.  The  section  was  mounted, 
without  covering,  in  70  per  cent,  alcohol.  A  small  piece  of  metallic 
sodium  was  then  placed  in  the  fluid  near  the  section  and  the  reaction 
watched  under  the  microscope.  By  this  means  sodium  ethylate 
(C2H5'ONa),  with  sodium  hydrate  (NaOH),  was  produced.  The  former 
is  capable  of  saponifying  fats  in  the  cold.  A  large  crop  of  acicular 
crystals  (?  C2H5'ONa)  was  formed,  and  the  globules  of  the  arcus  dis- 
appeared. 

Fresh  sections  stained  with  Lugol's  solution  (iodine  dissolved  in  i 
per  cent,  solution  of  potassium  iodide)  stained  the  globules  yellow,  as 
is  the  case  with  most  tissues.  There  was  no  trace  of  amyloid  reaction. 

Canton's  statement  that  Bowman's  membrane  is  unaltered  is  in- 
accurate ;  as  shown  above,  it  is  the  main  cause  of  the  densest  part  of 
the  arcus  senilis. 

He  further  states  that  there  is  a  slight  elevation  of  the  cornea  at  the 
site  of  the  arcus.  This  is  also  inaccurate  ;  but  there  is  an  undoubted, 
though  usually  slight,  diminution  in  the  thickness  of  the  cornea  peri- 
pheral to  the  arcus.  The  contrast  probably  led  to  the  error.  This 
slight  thinning  of  the  cornea  outside  the  arcus  points  to  a  condition  of 
sclerosis  as  a  constant  accompaniment  of  the  degeneration.  If  this  be 
so,  it  is  interesting  in  connection  with  those  rare  cases  of  peripheral 
sclerosis  and  peripheral  atrophy  (Randsclerose  and  Randatrophie) 
which  Fuchs  has  recently  described,  and  which  only  occur  in  associa- 
tion with  a  previously  established  arcus  senilis  (v .  p.  247). 

It  is  difficult  to  reconcile  my  observations  with  those  of  Fuchs  and 

1  BOLTON,  Jl.  of  Anat.  &  Phys.,  xxxii ;   Z.  f.  wiss.  Mikr.,  xv. 

2  MACALLUM,  Jl.  of  Phys.,  xxiii,  Supplement. 


236  THE    PATHOLOGY    OF   THE    EYE 

Leber,  but  in  all  probability  they  examined  cases  in  which  other 
degenerative  changes  were  present,  masking  the  true  arcus,  which 
would  have  disappeared  in  the  specimens  mounted  in  Canada  balsam. 

The  conclusions  arrived  at  by  Tweedy  and  Treacher  Collins  are 
chiefly  explicable  by  the  behaviour  of  the  globules  to  osmic  acid. 
Even  Takayasu,  whose  results  I  confirm  for  the  most  part,  states  that 
the  globules  stain  with  osmic  acid,  though  with  difficulty.  I  agree  that 
they  become  blacker,  but  this  is  no  evidence  of  a  true  fat  stain,  for  I 
have  proved  that  the  osmic  acid  is  not  reduced.  This  result  introduces 
a  complication  into  the  explanation  of  the  action  of  Sudan  III  and 
Scharlach  R.  It  has  been  shown  by  Altmann  and  others l  that  osmic 
acid  only  stains,  i.  e.  is  only  reduced  by  fats  which  are  glycerides  of 
the  chemically  unsatisfied  acrylic  series  of  acids  (CHH2,,_1'COOH, 
of  which  olein  is  the  commonest  representative  in  animal  tissues. 
Sudan  III  was  first  used  by  Daddi,3  the  idea  of  its  utility  for  micro- 
scopic purposes  being  derived  from  the  fact  that  it  was  used  commer- 
cially for  staining  fatty  preparations,  e.g.  pomades,  etc.  The  nature 
of  the  dye  and  of  its  congener  Scharlach  R,  which  is  chemically  azo- 
orthotoluol  azo-j3-napthol — 

— N=N— /> 
• — CH.j 


(Sudan  III  having  the  same  formula,  except  that  the  two  H's  have  not 
been  replaced  by  (CHS)  groups)  has  been  worked  out  by  Michaelis.3 
He  explains  their  action  upon  the  same  principle  as  that  of  osmic  acid, 
viz.  that  reduction  of  the  stain  is  brought  about  by  the  action  of  fatty 
acids  of  the  acrylic  series.  If  this  is  true  we  should  expect  osmic  acid, 
Sudan  III,  and  Scharlach  R  to  invariably  act  in  the  same  manner. 
This  is  not  the  case  with  arcus  senilis,  and  we  are  forced  to  the  con- 
clusion, either  that  there  is  some  flaw  in  the  chemistry  of  the  action  of 
these  stains,  or  what  is  more  probable,  that  osmic  acid  is  more  stable 
than  the  aromatic  stains,  which  are  reduced  by  a  smaller  amount  of,  or 
by  less  potent  members  of,  the  acrylic  series. 

It  was  thought  possible,  on  account  of  the  common  occurrence 
of  cholesterin  in  senile  degenerations,  that  the  fat-like  material 
might  be  a  cholesterin  ester,  or  ethereal  salt  of  a  fatty  or  other 
acid.  These  bodies  occur  in  large  quantities  in  lanoline.  The  sup- 
position was  improbable  a  priori,  ior  most  cholesterin  esters  are 
insoluble  in  alcohol.  On  saponification  they  are  split  into  the  acid  and 
cholesterin,  which  is  an  alcohol  with  the  formula  C27H45*OH.  It  was 
just  possible,  if  they  were  present,  that  cholesterin  would  crystallise  out 
in  its  typical  form  upon  the  slide,  when  the  section  was  treated  with 
sodium  ethylate.  This,  however,  did  not  occur. 

Most  fats  are  not  readily  soluble  in  alcohol,  and  the  globules  of  the 

1  See  HANDWERCK,  Z.  f.  wiss.  Mikr.,  xv. 

2  DADDI,  Arch.  ital.  de  Biol.,  xxvi. 

3  MICHAELIS,  Virchow's  Archiv,  clxiv. 


THE    CORNEA  237 

arcus  senilis  show  less  solubility  in  it  than  in  ether,  but  probably  more 
than  most  fats. 

In  conclusion  it  may  be  stated  that  the  arcus  senilis  is  probably  a 
fatty  degeneration  of  the  substantia  propria  of  the  cornea,  the  exact 
chemical  nature  of  the  fatty  material  being  still  undetermined. 

CANTON. — Lancet,  1850;  The  Arcus  Senilis,  London,  1863.  WILLIAMS. — Quoted  by 
Canton,  p.  18.  His. — Beitrage  zur  nor.  und  path.  Anat.  der  Cornea,  Basel,  1856. 
VIRCHOW. — Virchow's  Archiv,  iv,  1852.  FUCHS. — A.  f.  O.,  xxxvii,  3,  1891.  LEBER. — In 
Vossius,  Lehrbuch.  TWEEDY. — Quain's  Diet,  of  Med.,  art.  "  Arcus  Senilis."  TAKAYASU. — 
A.  f.  A.,  xliii.  PARSONS. — R.  L.  O.  H.  Rep.,  xv,  2,  1902. 


FATTY  INFILTRATION  AND  DEGENERATION 

Fatty  infiltration  and  degeneration  of  the  cornea  occurs  typically 
in  the  form  of  arcus  senilis  (q.  v.).  It  has  also  been  described 
occasionally  in  other  conditions,  in  the  form  of  large  globules  (Baum- 
garten),  and  in  large  aggregations  in  widened  lymph-spaces,  recalling 
the  histological  features  of  xanthelasma  (Kamocki).  Probably  it  is 
frequently  overlooked,  owing  to  the  routine  methods  of  embedding 
eyes  for  examination,  the  fat  being  dissolved  out  by  the  reagents  used. 

BAUMGARTEN. — A.  f.  O.,  xxii,  2,  1876.     KAMOCKI. — A.  f.  O.,  xxxix,  4,  1893. 


HYALINE,  COLLOID,  AND  AMYLOID  DEGENERATION 

Deposits  of  hyaline  substances,  which  give  various  staining  re- 
actions, are  common  in  old  leucomata,  anterior  staphylomata,  band- 
shaped  opacity  (q.  v.),  etc.  They  look  deep  yellow  to  the  naked 
eye,  and  may  project  above  the  surface.  They  are  usually  limited  to 
the  superficial  layers,  and  appear  microscopically  as  homogeneous, 
highly  refractile  globules  (Fig.  161).  The  earliest  deposits  are  minute 
granules;  these  coalesce  into  round  globules,  and  finally  into  large 
masses,  which  usually  show  their  mode  of  growth  by  accretion  in  their 
crenate  edges.  The  material  is  very  insoluble,  resisting  most  reagents, 
except  concentrated  alkalies  and  acids.  They  stain  deeply  with  acid 
fuchsin  and  methylene  blue,  partially  or  not  at  all  with  haematoxylin 
and  carmin.  Weigert's  fibrin  stain  colours  the  granules,  not  the  larger 
globules,  or  only  at  the  edges.  Weigert's  elastic-tissue  stain  colours 
the  larger  globules  red.  They  stain  deeply  with  Weigert's  and  Pal's 
medullary  stains.  Russel's  and  Gabbet's  stains  colour  the  granules 
deep  red,  the  cells  greenish  blue  or  blue,  van  Gieson's  stain  colours 
the  deposits  variously — yellow,  orange,  or  brown.  The  variety  of 
the  staining  reactions  shows  clearly  here,  as  elsewhere,  in  the  con- 
junctiva, etc.,  that  we  are  dealing  with  no  stable  chemical  body.  This 
is  further  shown  by  the  fact  that  the  amyloid  reactions  are  sometimes 
given  quite  typically,  but  far  more  frequently  in  an  indefinite  manner, 
or  not  at  all  (v.  p.  96). 

These  deposits  have  long  been  known  and  figured  (de  Vincentiis, 
Saemisch,  Goldzieher,  Wedl  and  Bock).  Beselin  was  the  first  to 
demonstrate  amyloid  in  the  cornea  of  a  staphylomatous  eye.  It  has 


238  THE    PATHOLOGY   OF   THE    EYE 

since  been  found  by  E.  von  Hippel  in  two  eyes.  Kamocki  regarded 
the  material  as  identical  with  v.  Recklinghausen's  "hyalin"  in  his 
observations.  Baquis  prefers  the  term  "  colloid,"  defining  it  as  a 
substance  which  is  very  closely  related  to  amyloid.  The  theory  of  the 
conversion  of  "  hyalin  "  into  amyloid  has  been  discussed  elsewhere 
(v.  p.  96).  Birch-Hirschfeld,  dealing  with  the  cornea,  sums  up  in 
favour  of  three  stages :  (i)  giving  the  staining  reactions  of  fibrin  ;  (2) 
giving  the  hyalin  or  colloid  reactions ;  (3)  giving  the  amyloid  re- 
actions. 

Baquis  was  able  to  examine  an  early  and  progressive  condition. 
The  epithelium  was  implicated  as  well  as  the  substantia  propria,  fine 
granules  appearing  in  the  cells  in  the  first  stage,  staining  with  fuchsin 


FIG.  161. — BAND-SHAPED  OPACITY,      x  90. 

The  dark  amorphous  and  globular  masses  near  the  surface  consist  of  hyaline 
material.  There  were  calcareous  deposits  in  the  same  situation  elsewhere.  The 
middle  layers  of  the  substantia  propria  are  infiltrated  and  vascularised. 

from  the  beginning.  The  intercellular  spaces  were  often  filled  with 
colloid  material,  and  the  cells  had  often  run  together,  and  were 
surrounded  by  a  ring  of  the  substance.  The  corneal  cells  also  take 
part  in  the  formation  of  colloid.  At  the  periphery  of  the  affected  area 
the  lymph-channels  were  distended  with  clear  fluid,  and  the  cells  were 
flattened  or  swollen,  and  often  devoid  of  nuclei.  Elsewhere  were 
transitions  to  masses  of  granules  in  the  channels  ;  these  stained  more 
and  more  deeply  with  fuchsin,  and  finally  ran  together  into  homo- 
geneous globules. 

Birch-Hirschfeld  examined  four  cases.  The  epithelium  was  normal 
in  the  peripheral  parts  and  in  some  places  where  there  were  already 
deposits  in  the  anterior  layers  of  the  substantia  propria.  Nearer  the 


THE   CORNEA  239 

centre  it  was  much  thickened,  with  conical  downgrowths  into  the 
connective  tissue.  Here  Bowman's  membrane  was  absent,  and  the 
downgrowths  were  surrounded  by  loose,  richly  cellular  connective  tissue. 
Groups  of  epithelial  cells  were  arranged  concentrically  or  spirally. 
Between  the  epithelium  and  the  fibrous  tissue,  and  in  the  epithelium 
itself,  were  deposits,  stained  bright  yellow  by  van  Gieson.  They  were 
chiefly  sickle  shaped,  with  the  convexity  towards  the  surface ;  others 
were  flat  or  spindle  shaped.  They  were  quite  homogeneous,  without 
any  lamination.  Only  a  few  of  the  smaller  granules  and  globules  were 
seen  in  the  epithelium,  and  these  were  all  between  the  deepest 
cylindrical  cells  ;  they  were  undoubtedly  extra-cellular.  Many  epithelial 
cells  were  necrosed,  and  had  fused  into  a  finely  granular  cellular 


FIG.  162.— HYALINE  DEGENERATION  OF  SCAR  TISSUE,      x  34. 
From  the  same  specimen  as  Fig.  108.     The  cornea  was  white  and  gelatinous. 
The  epithelium   is  very  irregular,  with   vesicles   in  many  parts.     The  substantia 
propria   is  transformed  into   whorls  and   masses  of  hyaline  material,  with  a  few 
leucocytes  and  small  blood-vessels  in  places. 

detritus,  in  which  a  few  nuclear  granules  stained  with  haematoxylin. 
A  special  modification  of  van  Gieson,  in  which  the  sections  were 
previously  stained  for  ten  minutes  with  3  per  cent,  picric  acid  fuchsin, 
was  held  to  prove  that  the  deposits  were  not  derived  from  the  broken- 
down  cells.  Nowhere  in  the  sections  was  any  protoplasmic  ring  or 
cell-membrane  to  be  seen  around  the  globules,  such  as  was  described 
by  Leber  in  amyloid  deposits  in  the  conjunctiva,  and  confirmed  by 
v.  Hippel.  The  epithelial  deposits  were  proved  by  serial  sections  to  be 
continuous  with  those  in  the  connective  tissue,  the  insular  nature  of 
the  deposits  being  only  apparent.  The  crescentic  shape  of  the  deposits 
is  best  explained  on  the  theory  that  fluid  passed  from  the  connective 
tissue  into  the  epithelium,  lifting  it  up  and  separating  the  cells.  It 


240 


THE    PATHOLOGY   OF   THE    EYE 


then  coagulated  and  became  degenerated  into  hyaline  masses.  That 
such  a  process  is  possible,  especially  after  the  destruction  of  Bowman's 
membrane,  is  shown  by  the  injection  experiments  of  Leber "-  and 
Raehlmann.3 

The  sub-epithelial  new  connective  tissue  consisted  of  rich  networks 
of  fibrillse,  with  rod-shaped  nuclei,  and  dilated  blood-vessels.  The 
globules  occurred  isolated  and  in  long  rows  between  the  bundles  of 
fibrils ;  they  were  chiefly  spherical,  the  smallest  being  about  the  size  of 
a  red  corpuscle.  In  places  they  seemed  to  form  a  continuation  of  the 
fibrils  themselves,  as  if  derived  from  them,  and  this  view  is  supported 
by  granules  within  the  corneal  lamellae.  Here,  again,  there  was  no 
evidence  of  their  derivation  from  the  cell-elements.  Only  a  few 
wandering  cells  were  present. 


FIG.  163. — HYALINE  DEGENERATION,      x  34. 

From  a  partial  anterior  staphyloma.  The  scar  tissue  on  the  surface  is  trans- 
formed into  whorls  and  clumps  of  hyaline  material,  which  contains  calcareous  salts 
in  parts.  The  masses  are  pushed  up  into  the  epithelium,  which  is  thus  made  very 
irregular,  though  the  levelling  tendency  is  still  apparent.  Towards  the  right  is  a 
vesicle  in  the  epithelium,  containing  hyaline  substance.  The  deeper  layers  of  the 
substantia  propria  are  infiltrated  and  vascularised.  Below  is  the  adherent 
degenerated  iris. 

Sachsalber  lays  stress  upon  the  conditions  found  in  the  epithelium, 
some  of  which  were  described  by  Birch-Hirschfeld.  Besides  the  usual 
degeneration  there  is  very  frequently  a  network  of  strands  composed  of 
horny  cells,  growing  down  into  the  deeper  layers  of  epithelium. 
Whorls  of  epithelial  cells  are  also  formed  around  the  concretions  ; 
many  of  the  inner  cells  are  flattened  and  look  like  connective-tissue 
cells.  The  sub-epithelial  connective  tissue  also  invades  the  epithelium, 
and  may  lead  to  the  isolation  of  groups  of  epithelial  cells,  which 

1  LEBER,  A.  f.  O.,  xiv. 

•  RAEHLMANN,  A.  f.  O.,  xxiii,  i. 


THE    CORNEA  241 

gradually  disappear,  and  are  replaced  by  concretions.  Patches  of 
softening  occur  in  the  epithelium,  leading  to  the  formation  of  cystic 
spaces. 

Various  theories  have  been  put  forward  to  account  for  these  hyaline 
masses.  There  can  be  no  doubt  that  the  fundamental  condition  is  one  of 
malnutrition,  and  probably  desiccation  plays  some  part  in  the  process, 
de  Vincentiis  regarded  the  substance  as  derived  from  the  cells,  Beselin 
from  the  lamellae  and  connective-tissue  fibrillse,  it  passing  subsequently 
between  the  epithelial  cells.  Kamocki  thought  the  process  a  hyaline 
degeneration  of  the  corneal  cells  or  scar  tissue.  E.  v.  Hippel  ascribed 
the  material  to  slow  degeneration  of  extravasated  blood.  Baquis  con- 
sidered it  partly  a  secretion  product  of  the  living  cells,  including  the 
epithelium,  partly  a  degeneration  product  of  necrosed  cells  and  red  and 
white  corpuscles,  and  partly  altered  exudate.  Birch-Hirschfeld  held 
that  ferments  produced  by  cell  necrosis  led  to  coagulation  of  fluid 
derived  from  the  blood,  the  whole  process  being  intercellular. 

Best  has  brought  forward  further  evidence  that  the  deposits  are 
altered  proteid  material,  most  allied  to  the  tyrosin  component.  With 
Millon's  reagent,  even  in  the  cold,  they  are  coloured  deep  brownish 
red  ;  but  they  are  not  pure  tyrosin,  as  shown  by  their  form,  the  absence 
of  red  colouration  with  sulphuric  acid,  and  the  absence  of  sulphur 
reaction.  If  sulphur  is  present  it  is  in  such  stable  combination  as  to 
give  no  reaction  with  basic  lead  acetate.  They  also  contain  the  uric 
acid  radicle,  as  shown  by  their  giving  the  biuret  reaction.  They  do  not 
contain  a  carbohydrate  molecule,  since  the  Adamkiewicz  and  Molisch 
reactions  are  negative.  Glycogen  is  absent,  though  it  occurs  in  other 
hyaline  deposits  in  the  eye. 

Sachsalber  considers  that  the  concretions  arise  in  the  scar  tissue  and 
corneal  stroma,  and  only  extend  secondarily  into  the  epithelium  ;  he 
regards  them  as  solely  extra-cellular. 

There  can  be  little  doubt  that  this  view  is  on  the  whole  correct. 
The  extrusion  of  the  exudates  and  fully  formed  concretions  leads  to 
thinning  of  the  epithelial  covering,  which  retains  as  long  as  possible  its 
smooth  surface.  Later  the  concretions  may  be  cast  off  into  the  con- 
junctival  sac,  but  this  probably  seldom  occurs  before  calcification  has 
taken  place.  The  spot  is  thus  denuded  of  epithelium,  and  a  path  is 
thrown  open  for  infection  (v.  p.  221). 

Besides  this  special  type  of  hyaline  degeneration,  simple  hyaline 
degeneration  of  scar  tissue  also  frequently  occurs  (v.  Figs.  108, 162, 163). 

DE  VINCENTIIS.— Contrib.  alia  Anat.  path,  dell'  Occhio.,  Napoli,  1873  ;  Lavori  della  Clin. 
ocul.  di  Napoli,  iv,  1896.  SAEMISCH. — In  G.-S.,  iv,  1876.  GOLDZIEHER. — C.  f.  A.,  iii,  1879. 
BESELIN. — A.  f.  A.,  xvi,  1886.  KAMOCKI.— A.  f.  A.,  xxv,  1892.  E.  v.  HIPPEL. — A.  f.  O., 
xli,  3,  1895.  DE  LIETRO  VOLLARO. — Lavori  della  Clin.  ocul.  di  Napoli,  iv,  1896.  LEBER. — 
B.  d.  o.  G.,  1897.  BAQUIS. — A.  f.  O.,  xlvi,  3,  1898.  BIRCH-HIRSCHFELD.— A.  f.  O.,  xlviii, 
2,  1899.  BEST. — B.  z.  A.,  xliii,  1900.  SACHSALBER.— B.  z.  A.,  xlviii,  1901. 

CALCAREOUS  DEGENERATION 

Calcareous  deposits  occur  in  the  cornea  under  similar  conditions  to 
hyaline  deposits  (see  "Band-shaped  Opacity").  Like  them,  they  are 
found  in  the  superficial  layers,  most  frequently  on  Bowman's  membrane  or 

16 


242 


THE    PATHOLOGY    OF   THE    EYE 


between  the  lamellae  of  the  substantia  propria  (Fig.  164).  They  form 
fine  granules  when  first  deposited,  and  later  laminae,  or  round  and 
irregular  nodules  of  various  sizes.  They  often  occur  combined  with 
hyaline  deposits.  The  walls  of  new-formed  vessels  may  also  be  hyaline 
or  calcareous. 

The  calcareous  parts  stain  deeply  and  diffusely  with  haematoxylin 
and  stains  containing  alum.  This  occurs  also  after  decalcification  if, 
as  is  usual,  the  material  is  in  intimate  organic  combination.  The 
calcium  salts  found  are  the  carbonate  and  phosphates.  The  former 
gives  off  gas  bubbles  with  acids,  and  forms  the  typical  "envelope" 
crystals  with  oxalic  acid.  The  actual  amount  of  calcium  salts  present 
is  often  extremely  small,  so  that  it  is  quite  possible  to  cut  thin  sections 
without  previously  decalcifying.  In  this  respect  the  cornea  differs  from 


FIG.  164. — CALCAREOUS  DEPOSITS  IN  THE  CORNEA,  x  200. 
The  basal  cells  of  the  epithelium  are  elongated  and  vacuolated  ;  there  is  some 
vacuolation  of  the  middle  layers.  The  tension  of  the  eye  was  sub-normal.  Below 
the  epithelium  are  plaques  of  calcareous  material,  deeply  stained  with  hsematoxylin. 
Below  these  are  the  earliest  dusty  deposits  of  calcareous  salts.  At  the  lowest  part 
of  the  figure  are  several  blood-vessels,  containing  red  corpuscles. 

the  choroid.  Consequently  it  may  be  impossible  to  demonstrate  the 
presence  of  the  carbonate  by  gas  bubbles  given  off  with  acids  in  sections 
under  the  microscope.  Larger  pieces  usually  show  them  plainly.  The 
lime  salts  are  generally  deposited  upon  an  albuminous  basis,  and  when 
this  is  dissolved  by  alkalies  the  deposits  are  seen  to  clear  up  as  they  do 
with  acids,  but  not  so  well. 

Calcareous  deposits  in  and  on  Bowman's  membrane  lead  to  its 
being  broken  up,  both  vertically  and  longitudinally,  and  displaced  or 
folded.  In  sections  it  often  shows  a  double  contour.  The  masses  are 
frequently  pushed  up  into  the  epithelium,  which  is  always  more  or  less 
altered,  and  is  often  degenerated  and  atrophic.  There  is  also  often 


THE    CORNEA  243 

new-formed  connective  tissue  around  the  calcareous  masses,  due  to  the 
irritation  which  they  set  up,  and  this  is  sometimes  emphasised  by  the 
presence  of  giant-cells. 

Hyaline    concretions    always    become    calcareous    eventually,    but 
calcification  also  occurs  by  primary  deposition  (Leber,  Sachsalber). 

LEBER. — B.  d.  o.  G.,  1897.     BEST. — B.  z.  A.,  xliii,  1933.     SACHSALBER. — B.  z.  A.,  xlviii, 
1901. 


BAND-SHAPED  OPACITY 

Band-shaped  opacity  was  first  described  by  Dixon  in  1848 — almost 
simultaneously  by  Bowman.  Dixon  called  it  calcareous  deposit  or 
calcareous  film,  and  it  has  since  received  many  other  names,  of  which 
the  following  are  a  selection : — Transverse  film,  band-  or  ribbon-shaped 
opacity  (v.  Graefe),  girdle-shaped  opacity  (Arlt),  band  keratitis  (Ober- 
tiischen),  symmetrical  opacity  (Fairlie  Clarke),  trophic  keratitis  (Magnus), 
zonular  opacity  (Fuchs),  etc.  An  excellent  resume  of  the  early  accounts 
up  to  1879  will  be  found  in  a  paper  by  Nettleship. 

The  opacity  forms  a  grey  stripe,  3 — 5  mm.  broad,  passing  horizon- 
tally across  the  cornea  a  little  below  its  centre,  i.  e.  in  the  part  corre- 
sponding with  the  palpebral  aperture  (Fig.  165).  It  develops  very 
slowly,  occupying  years  in  its  progress.  The  first  parts  to  appear  are 
the  two  ends,  and  these  are  always  separated  from  the  margin  of  the 
cornea  by  a  narrow  transparent  zone.  The  opacity  gradually  spreads 
towards  the  centre  of  the  cornea  from  each  side ;  when  complete  the 
two  extremities,  being  the  oldest  parts,  are  broadest  and  most  opaque. 
It  is  possible  the  pressure  of  the  lids  may  partly  account  for  the  peculiar 
shape  and  development  (Treacher  Collins).  When  examined  with  a 
loup  the  surface  is  seen  to  be  uneven, 
owing  to  multitudes  of  white  or  grey 
dots. 

The  condition  is  found  in  two  dis- 
tinct forms  :  (i)  a  primary  form,  which 
is  very  rare,  and  occurs  in  elderly  people 
whose  eyes  are  otherwise  quite  sound  ; 
(2)  a  secondary  form,  which  is  common, 
occuring  in  eyes  which  are  nearly  or 
quite  blind,  usually  from  irido-cyclitis 
(shrunken  globes,  etc.).  The  primary 
form  has  not  been  examined  micro- 
scopically. 

Dixon,    in   1848,  proved  the   pre- 
sence of  calcium  carbonate  and  phos-       FIG.  165.— BAND-SHAPED  OPACITY. 
phate    in    particles    removed    from    the  From  an  eye  with  irido-cyclitis. 

film.     It   is  interesting   to   note   that 

his  case  was  one  of  the  primary  form.  The  earliest  microscopical 
examination  is  by  Nettleship  (1873)  :  the  cornea  showed  (i)  puckering 
of  Bowman's  membrane ;  (2)  perforations  in  this  membrane,  through 
which  passed  finely  wavy  fibrous  tissue;  (3)  lifting  up  of  the  epithelium 


244 


THE    PATHOLOGY    OF   THE    EYE 


by  this  eruption  of  organised  fibrous  tissue.  Bock  (1887)  first  investi- 
gated the  subject  exhaustively.  In  one  case  he  found  calcareous  par- 
ticles on  Bowman's  membrane  only,  under  which  was  a  thin  layer  of 
spindle-cells  and  vessels.  In  two  other  cases  the  substantia  propria 
was  replaced  by  new  connective  tissue,  in  which  lay  calcareous  granules 
and  calcified  vessels.  Usher  (1893)  examined  thirteen  cases  ;  he  con- 
firms the  arrangement  of  the  fibrous  tissue  and  the  presence  of 
calcareous  deposits.  He  points  out  that  the  cornea  is  usually  thickest 
at  the  opacity,  and  that  the  new  tissue  is  sometimes  delimited  from 
the  substantia  propria  by  granular  bands. 

Leber  (1897)  came  to  the  conclusion  that  the  deposition  of  lime- 
salts  always  occurred  first  in  Bowman's  membrane.     In  some  cases 


FIG.  166. — BAND-SHAPED  OPACITY,      x  60. 

The  shape  of  the  hyaline  globules,  which  are  larger  in  this  specimen  than  in 
Fig.  161,  is  well  seen.  Some  are  present  in  the  epithelium.  The  stroma  below  is 
cedematous  and  contains  very  few  nuclei. 

the  calcified  membrane  lay  free  and  was  covered  with  coral-like 
excrescences.  He  considered  that  it  is  caused  by  drying  in  the  area 
exposed  by  the  palpebral  aperture,  so  that  the  little  soluble  lime-salts 
are  precipitated ;  they  are  probably  present  in  undue  quantity,  though 
the  reason  for  this  is  not  given.  Leber  regards  the  connective-tissue 
proliferation  as  secondary,  and  this  is  confirmed  by  a  case  of  Schieck's, 
in  which  Bowman's  membrane  was  calcified,  but  there  was  fibrous 
tissue  present  only  in  the  most  advanced  parts. 

Not  only  are  calcareous  deposits  present,  but  also  hyaline  ("colloid  ") 
globules  (Fig.  166).  They  have  been  observed  by  Bock,  Goldzieher, 
Schrader,  Kamocki,  Birch-Hirschfeld,  myself,  and  many  others.  They 
are  perhaps  commoner  in  old  leucomata,  but  they  must  be  regarded  as 


THE    CORNEA  245 

an  integral  part  of  the  picture  of  band-shaped  opacity,  though  this 
view  is  opposed  by  Greeff. 

Best  distinguishes  three  types  of  the  condition.  In  the  commonest 
sclerosing  fibrous  tissue  is  insinuated  between  the  epithelium  and  the 
superficial  lamellae,  so  that  Bowman's  membrane  is  much  degenerated, 
and  often  destroyed  in  parts,  elsewhere  split  and  fibrillated  and  em- 
bedded in  fibrous  tissue  and  epithelium.  This  fragmentation  of  Bowman's 
membrane  was  first  described  by  Samter ;  it  was  found  with  different 
variations  in  all  of  Usher's  thirteen  cases.  The  epithelium  is  often 
thickened,  and  elsewhere  thinned  or  destroyed,  as  is  so  frequent  in 
these  degenerative  conditions.  The  new  connective  tissue  is  poor  in 
vessels,  or  non-vascular.  Occasionally  giant-cells  are  found  near  the 
calcareous  masses,  induced  by  the  irritation  set  up.  Best,  comparing 
the  earlier  marginal  with  the  later  central  parts,  considers  the  new 
fibrous  tissue  to  be  formed  earlier  beneath  Bowman's  membrane  than 
between  it  and  the  epithelium. 

The  second  type  corresponds  with  an  earlier  stage,  in  which  the  band 
is  incomplete  in  the  centre  of  the  cornea.  Sections  through  this  part 
show  already  a  very  thin  layer  of  connective-tissue  nuclei  beneath 
Bowman's  membrane,  which  is  here  very  broad,  as  if  redematous. 
The  thickened  epithelium  is  raised  by  an  albuminous  exudate,  which  is 
continuous  peripherally  with  new  fibrous  tissue.  The  condition,  with 
the  subsequent  isolation  and  destruction  of  Bowman's  membrane,  may 
be  compared  with  pannus. 

The  third  type  corresponds  with  Leber's  description,  and  is  not 
common.  Bowman's  membrane  is  uncovered  by  epithelium  and  shows 
coral-like  excrescences.  These  contain  a  few  leucocytes  and  nuclear 
fragments,  but  are  otherwise  granular.  They  stain  by  Weigert's  fibrin 
stain,  and  partly  by  Gram,  forming  a  strong  contrast  to  the  red, 
carmin-stained,  calcareous  Bowman's  membrane.  They  probably 
consist  of  fibrinoid  coagulum,  containing  the  debris  of  epithelial  and 
round-cells. 

DIXON. — Diseases  of  the  Eye,  3rd  ed.,  p.  114,  1848.  BOWMAN. — Lectures,  p.  117,  1849. 
NETTLESHIP. — R.  L.  O.  H.  Rep.,  vii,  4,  1873.  GOLDZIEHER.— C.  f.  A.,  iii,  1879.  NETTLE- 
SHIP. — A.  of  O.,  viii,  1879.  BOCK. — Zur  Kentniss  der  bandformigen  Hornhautrubung, 
Wien,  1887.  SAMTER. — Inaug.  Diss.,  Konigsberg,  1890.  USHER. — R.  L.  O.  H.  Rep.,  xiii, 
4,  1893.  LEBER. — B.  d.  o.  G.,  1897.  SCHIECK. — Internat.  Cong.,  Utrecht,  1899:  v.  Hippel's 
Festschrift.  Halle,  1900.  *  BEST. — B.  z.  A.,  xliii,  1900.  MANZUTTO. — B.  z.  A.,  xliv,  1900. 
TREACHER  COLLINS. — Lancet,  1900. 


NODULAR  OPACITY 

Nodular  opacity  of  the  cornea  (knotchenformige  Homhanttriibung) 
was  described  by  Groenouw,  and  has  been  more  recently  investigated 
by  Fuchs.  Raised  grey  spots  are  scattered  over  the  cornea,  usually 
smaller  at  the  periphery  and  larger  near  the  centre,  where  they  may 
run  together  to  form  irregular  opaque  patches  (Figs.  167,  168).  The 
disease  is  probably  due  to  some  general  agent,  since  it  always  affects 
both  eyes,  develops  very  slowly,  requiring  many  years  for  completion, 
and  sometimes  occurs  in  several  members  of  the  same  family.  Similar 


246 


THE    PATHOLOGY   OF   THE    EYE 


cases  have  been  described  by  Chevallereau  (keratite  goutteme]  and 
Treacher  Collins.  The  condition  is  allied  to  the  reticular  opacity 
(q.  v.). 

Microscopically  Chevallereau  found  deposits  of  crystals  of  sodium 


FIG.   167. 


FIG.  1 68. 


FIGS.  167,  168.— NODULAR  OPACITY  OF  THE  CORNEA. 
Fuchs,  T.  O.  S.,  xxii ;  see  also  A.  f.  O.,  liii. 

urate  in  his  case.  Groenouw  found  hyaline  deposits,  staining  deeply 
with  eosin.  Fuchs  made  an  exhaustive  examination  of  portions  of  the 
cornea  removed  from  one  of  his  cases  with  the  corneal  trephine.  The 
changes  were  of  four  kinds,  and  were  limited  to  the  superficial  layers, 
(i)  The  lamellae  for  a  maximal  thickness  of  0*06  mm.  stained  faintly 
(Fig.  169),  especially  with  van  Gieson.  In  places  the  lamellae  were 
swollen  and  more  homogeneous,  and  the  lymph-channels  were  dilated, 
oval,  or  rhombic.  The  corneal  corpuscles  and  their  nuclei  were  swollen 
here.  Bowman's  membrane  was  absent.  There  was  therefore  the 


FIG.  169. — NODULAR  OPACITY  OF  THE  CORNEA. 
Fuchs,  T.  O.  S.,  xxii ;  see  also  A.  f.  O.,  liii. 

picture  of  marked  cedema  in  this  situation.  (2)  In  the  altered  super- 
ficial layers  were  raised  spots  corresponding  with  the  larger  grey 
opacities,  having  a  maximum  breadth  of  o-5  mm.  The  lamellae  were 


THE    CORNEA  247 

split  up  here  into  fine  wavy  fibres  with  spaces  between  them.  The 
epithelium  was  slightly  raised  by  the  nodules,  but  this  was  partially 
counteracted  by  diminution  in  the  number  of  layers,  the  cells  of  which 
showed  the  degenerative  changes  usual  under  such  circumstances.  (3) 
In  places,  especially  where  the  changes  were  most  advanced,  amorphous 
masses  lay  between  the  swollen  and  the  normal  lamellae.  These 
contained  broken  up  lamellae  and  distorted  nuclei.  The  amorphous 
material  was  finely  granular,  stained  little  with  hsematoxylin  and  eosin, 
yellow  with  van  Gieson  ;  it  was  probably  coagulated  fluid.  It  gave  no 
definite  mucin  reaction  with  rnucicarmin  or  thionin.  (4)  The  super- 
ficial layers  of  the  lamellae,  which  were  apparently  normal  when  stained 
with  hasmatoxylin  and  eosin  or  van  Gieson,  showed  changes  with  other 
stains.  They  were  coloured  violet  instead  of  blue  by  thionin  ;  blue 
with  Loffler's  methylene  blue  when  the  normal  ones  were  decolourised, 
and  the  same  with  Gram.  The  changes  point  to  a  mucoid  degeneration 
which  was  lost  in  the  later  stages. 

GROENOUW. — A.  f.  O.,  xlvi,  i,  1898.  *  FUCHS. — A.  f.  O.,  liii,  3,  1902.  CHEVALLEREAU. 
— France  medicale,  1891.  TREACHER  COLLINS. — T.  O.  S.,  xxii,  1902.  FEHR. — C.  f.  A., 
xxviii,  1904. 

RETICULAR  OPACITY 

Reticular  opacity  of  the  cornea  has  been  described  by  Biber,  Haab 
(gitterige  Keratitis),  and  Dimmer ;  cases  recorded  by  Treacher  Collins 
and  Block  probably  belong  to  this  category.  There  is  a  lattice-work  of 
fine  raised  lines  in  the  superficial  layers  of  the  cornea  ;  they  are  at  first 
transparent,  but  become  grey.  The  condition  resembles  nodular 
opacity  in  the  chronic  course  of  the  disease  and  the  occasional  affection 
of  members  of  the  same  family. 

Dimmer  examined  a  small  portion  of  cornea  removed  from  a  case. 
The  grey  lines  do  not  lie  in  the  epithelium,  but  in  the  superficial  layers 
of  the  substantia  propria,  and  are  probably  due  to  folding  of  Bowman's 
membrane  (Dimmer).  Besides  the  fine  lines  there  are  minute  grey 
punctate  opacities,  which  project  above  the  surface.  These  consist  of 
a  hyaline  material,  insoluble  in  alcohol,  ether,  and  strong  acids,  and 
stained  by  eosin.  There  were  needle-shaped  crystals  in  the  epithelium, 
which  dissolved  in  mineral  acids  without  giving  off  gas  ;  they  wrere 
probably  triple  phosphate  (Dimmer). 

BIBER. — Dissert.,  Zurich,  1890.  HAAB. — Z.  f.  A.,  ii,  1890.  DIMMER. — Z.  f.  A.,  ii,  1890. 
TREACHER  COLLINS. — T.  O.  S.,  xix,  1899.  BLOCK. — Niederl.  ophth.  Gesellschaft,  1899. 
FREUND. — A.  f.  O.,  xlii,  2,  1903. 

PERIPHERAL  SCLEROSIS  AND  ATROPHY 

Peripheral  sclerosis  and  atrophy  of  the  cornea  (Randsclerose  und 
Randatrophie  der  Hornhaut]  has  recently  been  described  by  Fuchs. 
Only  one  case  has  yet  been  examined  microscopically. 

Most  of  the  cases  occurred  in  old  people  in  connection  with  arcus 
senilis.  A  furrow  forms  spontaneously  at  the  periphery  of  the  cornea, 
without  any  ulceration  having  taken  place  (Fig.  170).  It  is  situated 
between  the  arcus  and  the  limbus,  and  may  surround  the  cornea ;  it 


248 


THE    PATHOLOGY    OF   THE    EYE 


may  also  occur  in  both  eyes.  The  central  wall  of  the  depression  is 
nearly  perpendicular,  the  peripheral  rises  gradually  ;  the  floor  is  covered 
with  epithelium,  and  is  vascularised  from  the  limbus  vessels. 

The  eye  which  was  examined  was  lost  from  glaucoma  ;  there  was 
no  ectasia  of  the  cornea.  The  gutter  was  0*55  mm.  broad  ;  the  floor 
was  o'57  mm.  thick — about  two-thirds  the  thickness  of  the  cornea  in 
the  centre.  Bowman's  membrane  ceased  more  than  2  mm.  from  the 
central  edge  of  the  furrow,  and  for  about  two-thirds  of  a  mm.  from  the 
edge  the  lamellae  were  broken  up,  wavy,  and  richly  vascularised.  The 
anterior  half  of  the  floor  consisted  of  the  same  tissue,  whilst  the  posterior 
half  consisted  of  normal  lamellae.  There  was  no  evidence  of  round-cell 
infiltration  or  of  any  inflammatory  process,  and  the  loose  tissue  was 


FIG.  170. — PERIPHERAL  SCLEROSIS  AND  ATROPHY  OF  THE  CORNEA,      x  55. 

From   a    specimen    sent  by   Prof.    Fuchs.     This   is   evidently  from   the   same 
specimen  which  is  described  by  Fuchs,  and  figured  in  A.  f.  O.,  lii. 

quite  unlike  a  corneal  cicatrix.  The  epithelium  was  thicker  over  the 
floor,  owing  to  protection  from  pressure.  The  characteristic  basal  cells 
of  the  corneal  epithelium  reached  only  to  the  central  steep  wall ;  on 
the  floor  was  conjunctival  epithelium,  distinguished  by  the  much 
shorter  cubical  basal  cells  with  deeply  stained  nuclei. 

The  condition  is  probably  due  to  an  advance  of  the  conjunctiva  into 
the  cornea,  brought  about  by  some  unknown  stimulus.  Bowman's 
membrane  is  destroyed,  and  the  lamellae  are  broken  apart,  fibrillated, 
and  in  large  degree  destroyed.  The  process  is  therefore  much  allied 
to  that  taking  place  in  pterygium. 

A  somewhat  similar  condition,  occurring  in  younger  people,  is 
mentioned  by  Fuchs,  and  is  probably  the  same  asTerrien's  "dystrophie 
marginale."  Schmidt-Rimpler's  "  chronic  peripheral  furrow  keratitis 


THE    CORNEA 


249 


(Fnrchenkeratitis) "  differs  from  peripheral  sclerosis  in  that  the  furrow 
is  central  to  the  marginal  opacity. 

*  PI-CMS. — A.  f.  O.,  Hi,  2,  1901.  TERRIEN. — A.  d'O.,  xx,  1900.  SCHMIDT-RIMPLER. — 
Lehrbuch,  jth  ed.,  p.  491. 

PIGMENTATION 

In  rare  cases  of  diffuse  pigmentation  of  the  conjunctiva  the  disease 
may  extend  on  to  the  cornea.  In  two  cases  which  I  have  seen  there 
were  tongue-shaped  pigmented  patches  passing  towards  the  centre  of 
the  cornea  from  the  periphery.  Microscopically  the  pigment  consisted 


FIG.  171. — BLOOD-STAINING  OF  CORNEA. 
Treacher  Collins,  T.  O.  S.,  xi. 

of  dense  clumps  situated  in  the  epithelium,  the  substantia  propria 
being  normal.  The  pigment  gave  no  iron  reaction,  and  was  bleached 
by  the  usual  methods. 

YAMAGUCHI. — K.  M.  f.  A.,  xlii,  1904. 

Pigmentation  of  the  cornea  is  usually  due  to  blood-pigment  or  to 
deposits  of  foreign  matter,  e.g.  metals,  Indian  ink,  etc.  Congenital 
opacities  are  occasionally  coloured  ;  they  will  be  considered  elsewhere. 

Blood=staining. — The  periphery  of  the  cornea  may  become 
stained  by  blood  after  sub-conjunctival  haemorrhage  in  the  vicinity. 
Pigmentation  of  the  cornea  as  the  result  of  haemorrhage  into  the 
anterior  chamber  occurs  with  comparative  rarity.  It  is  interesting 
clinically  in  that  the  condition  may  be  mistaken  for  dislocation  of  the 
lens  into  the  anterior  chamber.  In  many  of  the  cases  recorded  the 
tension  was  raised,  and  it  is  probable  that  it  is  raised  in  the  early 


250 


THE    PATHOLOGY    OF   THE    EYE 


stages  in  all  cases,  and  that  this  is  an  important  factor  in  determining 
the  transfusion  of  the  cornea  with  blood.  The  whole  cornea  is  at  first 
stained  ;  it  gradually  and  very  slowly  clears  from  the  periphery  towards 
the  centre.  In  one  case  it  took  twenty-five  days  to  clear  to  the  edge  of 
the  dilated  (atropinised)  pupil ;  a  year  after  there  was  a  grey  patch, 
4  mm.  in  diameter,  in  the  centre  of  the  cornea  ;  in  two  and  a  quarter 
years  the  cornea  was  clear  (Treacher  Collins).  The  colour  varies 
greatly,  probably  with  the  age  of  the  staining  ;  it  is  described  as 
greenish  black,  greenish  brown,  greenish,  rusty  brown,  reddish  brown, 
etc.  In  all  cases  there  is  at  first  hyphaema.  It  may  occur  at  any  age. 
Its  comparative  rarity  is  probably  due  to  the  absence  of  tension  at  the 


FIG.  172. — BLOOD-STAINING  OF  CORNEA. 
Griffith,  T.  O.  S.,  xiv. 

onset  of  most  haemorrhages,  the  tension  being  sub-normal,  owing  to  the 
presence  of  a  wound. 

The  nature  of  the  pigment  has  been  the  subject  of  much  con- 
troversy. It  doubtless  varies  with  the  age  of  the  deposit,  and  is 
invariably  a  derivative  of  haemoglobin.  According  to  Treacher  Collins, 
hsematoidin  is  the  chief  constituent;  but  this  is  not  always  the  case, 
since  the  deposit  often  gives  the  reactions  for  iron,  and  haematoidin 
contains  no  iron  ;  also  haematoidin  is  soluble  in  chloroform,  whereas 
the  granules  are  not  always  so  (E.  von  Hippel).  It  is  probable  that 
the  iron-containing  pigment  is  haemosiderin  (Vossius) ;  but  doubtless 
other  derivatives  of  haemoglobin  occur  at  various  stages. 

In  some  cases,  but  probably  a  minority,  there  is  actual  haemorrhage 
into  the  cornea  from  new-formed  vessels  (Vossius,  Scheffels),  for 
corpuscles  in  various  stages  of  degeneration  have  been  observed. 
There  can  be  no  question  that  many  of  the  cases  occur  without  intra- 


THE    CORNEA 


251 


corneal  haemorrhage.  In  these  the  haemoglobin  of  the  broken  down 
corpuscles  in  the  anterior  chamber  is  in  solution,  and  niters  through 
Descemet's  membrane  (Treacher  Collins),  or  possibly  enters  the 
cornea  through  the  spaces  of  Fontana  (Weeks),  but  this  is  less  pro- 
bable. 

It  is  natural  that  absorption  should  take  place  from  the  periphery, 
the  site  of  the  blood-vessels  and  most  active  lymph-flow.  In  cases  in 
which  new  capillaries  are  present  in  the  cornea  the  area  surrounding 
them  is  free  from  granules  (Baumgarten,  Vossius),  indicating  the 
activity  of  absorption  in  this  situation.  The  granules  are  extremely 
insoluble,  and  are  probably  removed  by  leucocytes. 

The  granules  are  usually  present  in  vast  numbers,  are  round,  oval, 


FIG.  173. — PIGMENT  IN  THE  CORNEAL  CORPUSCLES,      x   180. 
Vertical  section.     Slight  oedema  of  the  epithelium.     Bowman's  membrane  is 
fibrillated   and   destroyed    in    one    place  by    an    aggregation  of    leucocytes.     The 
corneal  corpuscles  are  packed  with  dark  granules. 

or  rod-shaped,  highly  refracting,  and  vary  in  size  from  3  fj.  to  7  /u;  they 
are  therefore  much  smaller  than  red  corpuscles  (Figs.  171,  172).  They 
are  generally  scattered  throughout  the  corneal  lamellae,  and  are  absent 
from  the  spaces.  A  few  are  present  between  the  epithelium  and 
Bowman's  membrane,  and  in  the  spaces  of  Fontana. 

These  granules  have  naturally  been  regarded  as  the  cause  of  the 
colouration  by  many  observers  (Lawford,  Griffith,  Treacher  Collins, 
etc.).  The  absence  of  colour  is  somewhat  against  this  idea,  and  the 
presence  of  distinct  pigmented  granules  in  the  corneal  corpuscles,  noted 
by  other  observers  (E.  von  Hippel),  has  led  to  their  being  regarded  as 
the  real  cause.  Indeed,  the  refractile  granules  may  be  entirely  absent 
(Romer,  Case  iii).  It  can  scarcely  be  doubted,  however,  that  in 


252 


THE    PATHOLOGY   OF   THE    EYE 


most  of  the  cases  they  are  the  cause  of  the  colouration.  Their  high 
refractility  is  itself  sufficient  to  mask  colouration  when  viewed  by 
transmitted  light. 

Leber  compared  the  granules  to  the  fibrin  deposits  found  by  him 
in  Aspergillus  keratitis.  This  has  been  definitely  disproved  by  Romer, 
who  concludes  that  they  are  formed  from  the  proteid  constituent  of 
haemoglobin,  which  has  further  undergone  hyaline  degeneration.  They 
do  not  stain  with  the  ordinary  fibrin  stains,  and  they  are,  unlike  fibrin, 
insoluble  in  a  solution  of  neurin  (Romer).  Vossius  regarded  them  as 
a  hyaline  degeneration  of  the  corneal  fibrillae.  Baumgarten  showed 
that  the  apparent  resemblance  to  micro-organisms  was  fallacious. 

The  granules  are  insoluble  in  alcohol,  ether,  and  chloroform  ;  they 


FIG.  174. — PIGMENT  IN  THE  CORNEAL  CORPUSCLES,      x   180. 
Tangential  section  from  the  same  specimen  as   Fig.  173.     The  corneal  cor- 
puscles are  packed  with  round  pigment  granules.     The  darkly  stained  rod-shaped 
and  broken  up  nuclei  belong  to  infiltrating  leucocytes. 

are  only  slowly  acted  upon  by  strong  acids  and  alkalies.  They  give  no 
glycogen  or  amyloid  reaction,  and  are  unstained  by  van  Gieson's  solu- 
tion, Weigert's  elastic  stain,  etc.  Nuclear  stains  (e.  g.  hsematoxylin, 
alum  and  lithium  carmin)  do  not  stain  them,  nor  aniline  dyes,  e.g. 
Bismarck  brown,  gentian  violet,  methylene  blue.  They  are  not  stained 
by  osmic  acid.  They  are  stained  pink  by  eosin,  or  haematoxylin-carbol- 
fuchsin  ;  red  by  hsematoxylin-saffranin-picric  acid.  Intense  over-stain-- 
ing  with  Weigert's  fibrin  stain  colours  them  faintly  (Romer).  They  are 
stained  by  iodine-green  or  methyl-green  (Griffith). 

I  have  seen  an  anomalous  case  in  which,  following  a  perforating 
wound  with  a  splinter  of  steel,  the  cornea  and  other  parts  of  the  eye 
were  intensely  pigmented.  No  foreign  body  was  found  on  examination, 


THE    CORNEA  253 

but  there  was  considerable  intra-ocular  haemorrhage.  The  pigment 
granules  were  confined  to  the  corneal  corpuscles  (Figs.  173, 174).  They 
gave  a  well-marked  iron  reaction. 

BAUMGARTEN. — A.  f.  O.,  xxix,  3,  1883.  LAWFORD. — T.  O.  S.,  viii,  1888.  Vossius. — 
A.  f.  O.,  xxxv,  2,  1889.  LEBER. — A.  f.  O.,  xxxv,  i  and  2,  1889.  *  TREACHER  COLLINS. — 
T.  O.  S.,  xi,  1891 ;  xv,  1896.  WEEKS. — New  York  Eye  and  Ear  Infirmary  Rep.,  1893 
GRIFFITH. — T.  O.  S.,  xiv,  1894.  HIRSCHBERG. — C.  f.  A.,  xx,  1896.  E.  v.  HIPPEL. — A.  f.  O., 
xliv,  3,  1897.  *  ROMER. — Vossius'  Sammlung,  ii,  8,  1899.  SCHEFFELS. — Z.  f.  A.,  v.  1901. 

Metals. — Deposits  of  lead,  iron,  silver,  copper,  etc,,  have  been 
described  in  the  cornea  as  the  result  of  treatment  or  accident.  In 
argyrosis  Knies  found  intense  staining  of  Descemet's  membrane  with 
silver,  whilst  the  other  parts  of  the  cornea  were  normal.  This  might 
be  anticipated  from  the  affinity  shown  by  silver  for  elastic  fibres 
(v.  p.  no).  Deposits  of  lead  upon  ulcers  treated  with  Lotio  plumbi  are 
quite  superficial.  Iron  staining  will  be  described  elsewhere  in  treating 
of  siderosis  bulbi.  The  other  stains  are  rarities  which  have  been 
observed  only  clinically. 

KNIES.— K.  M.  f.  A.,  xviii,  1880. 

Tattooing. — The  deposits  of  pigment  in  leucomata  after  tattooing 
were  first  examined  by  Hirschberg,  whose  results  I  can  confirm.  The 
black  pigment  forms  spindle-shaped  or  irregular  lumps  between  the 
fibres  of  the  scar  tissue.  It  is  mostly  free,  but  granules  are  found  in 
some  of  the  cells,  probably  in  process  of  removal,  and  also  in  the  walls 
and  lumina  of  vessels.  Only  the  deepest  layers  of  the  epithelium  ever 
contain  pigment. 

HIRSCHBERG.— A.  f.  O.,  xxviii,  r,  1882. 


CYSTS 

Cysts  of  the  cornea  are  rare ;  they  are  mostly  implantation  cysts,  due 
to  injuries  or  operations,  whereby  particles  of  the  superficial  epithelium 
are  carried  into  the  stroma.  The  displaced  epithelium  then  proliferates, 
forming  a  mass  like  the  cholesteatomata,  or  pearl  tumours  of  the  iris. 
The  central  cells  break  down  and  disappear,  fluid  collects,  and  a  cyst  is 
formed  in  the  substance  of  the  cornea,  lined  by  stratified  epithelium. 
Such  cases  have  been  described  by  Treacher  Collins.  One  followed  a 
perforating  wound  with  a  shot ;  another  occurred  in  a  shrunken  eye 
from  which  a  cataract  had  been  extracted  (Fig.  175) ;  a  third  was  a 
large  cyst  following  a  perforating  wound  with  a  stick  (Figs.  176,  177). 
The  epithelium  is  usually  irregular  and  ill  developed;  the  number  of 
layers  varies  in  different  parts,  the  outer  ones  consisting  of  cubical  and 
the  inner  of  flattened  cells.  The  cavity  often  contains  granular  or 
hyaline  material,  and  there  are  often  patches  of  epithelium  without  any 
cavity.  The  corneal  tissue  around  is  generally  infiltrated  and  vascu- 
larised,  and  the  fibrous  tissue  is  especially  dense  immediately  around 
the  cysts. 


254 


THE    PATHOLOGY   OF   THE    EYE 


The  possibility  of  direct  continuity  with  the  superficial  epithelium 
in  these  cases  can  only  be  eliminated  by  serial  sections.  It  is  not 
uncommon  after  cataract  extractions,  usually  in  eyes  which  have  later 


d 


FIG.  175. — CYST  OF  CORNEA. 

From  Treacher  Collins.     Epithelial  cyst   in   cornea   of  a   shrunken   eye,  after 
cataract  extraction,     d,  Bowman's  membrane;  c,  cyst.     (R.  L.  O.  H.  Rep.,  xiii.) 

become  glaucomatous,  to  find  that  the  epithelium  has  grown  down  into 
the  cornea  or  sclera,  and  even  into  the  anterior  chamber.  The  track  is 
often  very  irregular  and  tortuous,  so  that  islets  of  epithelium  are  seen  in 
sections.  There  may  be  a  devious  fistulous  track  in  these  cases,  in  spite 
of  which  the  anterior  chamber  is  maintained,  the  tortuosity  allowing 
the  walls  to  be  kept  in  contact  in  places  by  the 
intra-ocular  tension  (v.  p.  165). 

Cystic  spaces  may  also  occur  with  uveal  pig- 
ment in  the  walls.  In  these  there  has  probably 
been  prolapse  of  iris,  which  has  been  treated. 
Alt  describes  four  cases,  in  two  of  which  the  cysts 
were  lined  by  uveal  pigment ;  another  had  per- 
fectly smooth  walls  ;  and  the  fourth  had  trabeculse 
passing  from  one  side  to  the  other.  There  is  no 
mention  of  an  epithelial  lining. 

Small  cysts  in  the  epithelium  (vesicular  or 
bullous  keratitis)  are  common  (v.  p.  176). 

Spurious  cysts  also  occur,  which  are  found  on 
microscopical  examination  to  consist  of  masses 
of  loose,  redematous  (?  myxomatous),  fibrous  tissue 
(Treacher  Collins). 
True  lymphatic  retention  cysts  are  of  great  rarity.    One  such  has  been 
described  by  Ginsberg  in  a  chick.     It  had  no  continuous  cellular  lining, 


FIG.  176. — CYST  OF 

CORNEA. 

From  Treacher  Collins. 
Epithelial  cyst  following 
wound  with  a  piece  of  wood. 
(T.  O.  S.,  xii.) 


THE    CORNEA  255 

but  only  an  incomplete  layer  of  flat  connective-tissue  cells.  It  probably 
arose  by  distension  of  the  lymphatic  channels,  and  absorption  of  some 
of  the  lamellae.  Another  case  has  been  recorded  by  Just,  but  without 
microscopic  examination. 

There  is  a  small  group  of  cases  in  which  cysts  have  developed  in 
conjunctiva  laying  on  the  cornea.  There  has  usually  been  previous 
injury  or  blenorrhoea,  and  the  condition  is  probably  due  to  the  forma- 
tion of  an  extensive  pseudo-pterygium  by  the  adhesion  of  the  chemosed 
conjunctiva  to  the  corneal  wound  or  ulcer.  The  simplest  expression  of 
the  condition  is  found  in  a  case  of  Reid's,  reported  by  Bietti.  Here  the 
conjunctival  epithelium  was  fused  to  the  corneal  at  some  distance  from 
the  limbus.  In  this  manner  an  epithelial  cyst  was  formed,  bounded  by 
conjunctiva  in  front  and  cornea  behind.  In  Bietti's  own  case  the  union 
was  more  intimate.  There  was  a  single  cyst  with  a  small  diverticulum, 
lined  by  stratified  epithelium  of  varying  thickness.  Bowman's  mem- 
brane was  destroyed  under  and  around  the  cyst,  and  the  corneal 


FIG.  177. — CYST  OF  CORNEA. 
From  Treacher  Collins.     Showing  laminated  epithelium  of  the  cyst  in  Fig.  176. 

lamellae  were  sclerosed  and  infiltrated.  The  condition  is  ascribed  to  a 
pseudo-pterygium  following  superficial  marginal  keratitis.  In  Schieck's 
case  there  was  a  trilocular  cyst  following  a  perforating  ulcer  with  pro- 
lapse of  iris.  Reis  reports  a  similar  case,  with  several  cysts.  They 
were  all  lined  with  stratified  epithelium  and  lay  principally  in  con- 
junctival tissue,  the  cornea  forming  a  posterior  basis. 

Czermak  describes  cystic  spaces  in  corneal  scars ;  in  all  the  cases 
the  iris  was  involved,  a  triangular  space  passing  along  the  iris  from  the 
anterior  chamber  towards  the  cyst  without  directly  communicating 
with  it. 

Gruening  reports  an  extraordinarily  large  cyst  developed  between 
the  layers  of  the  cornea  and  sclerotic  at  the  limbus,  in  a  girl  of  fourteen, 
after  an  iridectomy  (cf.  Fig.  176).  It  communicated  with  the  posterior 
chamber  by  two  minute  canals,  and  was  lined  irregularly  by  a  thin  layer 
of  endothelium. 

Tertsch  reports  a  cyst  of  the  posterior  part  of  the  cornea  in  a 
buphthalmic  eye.  Descemet's  membrane  was  separated  from  the  cor- 
neal lamellae,  and  formed  a  space  which  communicated  with  the  ante- 


256 


THE    PATHOLOGY   OF   THE    EYE 


rior  chamber  through  a  tear  in  the  membrane.  The  cyst  was  lined 
with  endothelium,  continuous  with  that  on  the  back  of  the  cornea. 
Descemet's  membrane  was  also  ruptured  in  other  places. 

*  TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xiii,  i,  1890;  T.  O.  S.,  xii,  1892.  ALT. — 
A.  of  O.  and  Otology,  vi,  1878.  GINSBERG. — C.  f.  A.,  xxi,  1897.  JUST. — Ann.  d'Oc.,  Ixx, 
1873.  BIETTI. — K.  M.  f.  A.,  xxxviii,  1900.  SCHIECK. — A.  f.  O.,  Hi,  2,  1901.  REIS. — 
K.  M.  f.  A.,  xl,  1902.  CZERMAK. — A.  f.  O.,  xxxvi,  2,  1890.  GRUEXING.— T.  Am.  O.  S., 
1901.  *  TERTSCH.— A.  f.  O.,  Ivi,  2,  1903. 


TUMOURS 
PAPILLOMA  AND  CORNEAL  "  HORN  " 

Bowman  described  a  "  warty  condition  "  of  the  cornea ;  this  refers 
to  epidermoid  epithelium  over  a  hyperplastic  scar.  The  first  true 
papilloma  was  described  by  Gayet  in  1879.  It  occurred  in  a  man  of 
sixty-seven,  and  involved  nearly  the  whole  of  the  cornea.  It  consisted 
of  papillae,  which  occupied  the  position  of  Bowman's  membrane,  and 
were  covered  by  corneal  epithelium.  It  probably  started  at  the  limbus 
and  invaded  the  cornea.  This  is  also  true  of  Ayres'  case. 

Baas  reported  a  "corneal  horn,"  which  consisted  of  a  papilla  covered 
by  horny  epithelium. 

Demicheri's  tumour  occupied  the  upper  and  inner  half  of  the  cornea, 
and  also  probably  began  in  the  limbus.     The  fibrous  tissue  was  slight 
and  poor  in  vessels. 

In  Lagrange's  case  there  was  a  large  caulirlower- 
like  growth,  the  pedicle  of  which  was  exactly 
circumscribed  by  the  limbus.  It  was  a  typical 
papilloma.  Bowman's  membrane  W7as  destroyed, 
but  some  of  the  deeper  layers  of  the  cornea  were 
intact,  and  the  eye  was  otherwise  healthy. 

Arnold  Lawson  has  published  a  case  of  "  cicatrix 
horn  "  growing  from  the  cornea  (Fig.  178).     It  was 
conical  in  shape,  five-eighths  of  an  inch  in  length, 
and  an  inch  and  a  half  round  the  base.     It  grew 
from  an  anterior  staphyloma,  and  consisted  of  an 
outer  layer  of  fibrillated  material,  staining  badly, 
and  an  inner  layer  occupying  three-quarters  of  the 
section,  composed  of  small,  round,  nucleated  cells. 
It  can  hardly  be  doubted  that  this  is  no  true  new 
growth,   but    merely  a   mass  of  granulation   tissue 
which   was   unusually   exuberant.      Projecting   between    the   lids,   the 
surface  became  dry,  and  the  detritus  was  not  cast  off  by  movements  of 
the  lids,  etc.,  owing  to  the  marasmic  condition  of  the  child. 

BOWMAX. — Lectures,  London,  1849.  GAYET. — Lyon  medical.,  1879.  AYRES. — Jl.  of 
the  Amer.  Med.  Assoc.,  1891  ;  Ophth.  Rev.,  x,  1891.  BAAS — Ziegler's  Beitrage,  xx. 
DEMICHERI.— A.  d'O./xix,  1899.  *  LAGRAXGE — Tumeurs  de  1'CEil,  i,  Paris,  1901.  ARNOLD 
LAWSOX. — T.  O.  S.,  xx,  1900. 


FIG.  178. — "  CORNEAL 

HORN." 
Lawson,  T.  O.  S.,  xx. 


THE    CORNEA  257 


FIBROMA 

Many  of  the  cases  described  as  fibromata  of  the  cornea  are  merely 
hyperplastic  scars.  To  this  group  belong  those  described  by  Pagen- 
stecher  and  Genth,  Scott  and  Story,  Silex,  Zirm,  Vossius,  Westcott, 
and  others.  These  occurred  respectively  in  an  old  scar,  in  trachoma, 
in  an  adherent  leucoma,  etc.  They  were  either  localised  swellings  or 
diffuse,  and  differed  in  no  respect  from  ordinary  pseudo-corneae,  except 
in  the  overgrowth  of  vascular  connective  tissue. 

A  case  described  by  Reishaus,  belonging  to  the  same  group,  offers 
some  peculiarities.  It  occurred  in  a  \voman  of  forty-six,  who  had  suf- 
fered for  years  from  chronic  conjunctivitis  with  papillary  hypertrophy. 
The  swelling  had  existed  for  two  years  or  more ;  it  was  hard,  reddish, 
and  covered  the  lower  half  of  the  lower  corneal  quadrant.  It  was 
cured  by  excision,  the  base  being  cauterised.  It  consisted  of  laminated 
connective  tissue,  rich  in  cells,  especially  near  the  vessels.  There  were 
no  tubercle  bacilli.  There  were  numerous  mast-cells,  and  also  many 
small  round  globules,  about  the  size  of  red  corpuscles,  which  stained 
with  aniline  dyes ;  red  with  fuchsin.  These  were  regarded  by  the 
author  as  blastomycetes ;  they  stained  bright  red  with  Busse's  specific 
stain. 

These  "  fuchsinophile  "  bodies  are  common  in  chronically  inflamed 
tissues,  and  are  probably  only  hyaline  bodies.  (On  the  subject  of 
blastomycetes  in  relation  to  the  eye,  see  Stoewer.1) 

Capellini  has  reviewed  the  published  cases  of  corneal  fibroma,  and 
added  two  others,  one  of  which  he  calls  a  true  fibroma,  as  opposed  to  a 
hyperplastic  scar,  and  the  other,  on  account  of  its  extreme  vascularity, 
a  telangiectatic  angio-fibroma.  Both  seem  to  me  to  be  more  probably 
types  of  hyperplastic  scars  (pseudo-corneae),  which  are  by  no  means 
infrequently  met  with. 

There  are,  however,  other  cases  which  are  apparently  true  fibromata 
of  the  cornea,  such  as  those  described  by  Quaglino  and  Guaita,  Falchi, 
Benson,  Gallenga,  Rogman.  Some  of  these  were  pedunculated  and 
polypoid,  growing  from  the  centre  of  the  cornea.  They  are  usually 
covered  with  epithelium,  which  resembles  "  corneal "  epithelium,  but 
may  have  mucous  cells  or  be  horny  on  the  surface.  The  growth  itself 
consists  of  irregular  bands  of  fibrous  tissue  with  scanty  flat  and  round 
cells.  More  rarely  the  bundles  are  laminated,  and  in  Rogman's  case 
the  growth  consisted  of  embryonic  spindle-shaped  cells. 

The  ages  of  the  cases  cited  were  48,  28,  19,  and  72,  4,  and  30  ;  three 
were  men  and  three  women. 

PAGENSTECHER  AND  GENTH. — Atlas,  Plate  xvi,  Wiesbaden,  1875.  SCOTT  AND  STORY. 
— Ophth.  Rev.,  1888.  SILEX.— K.  M.  f.  A.,  xxvi,  1888.  ZIRM.— A.  f.  O.,  xxxvii,  3,  1891. 
Vossius. — B.  d.  o.  G.,  1895.  WESTCOTT. — Ann.  of  Ophth.,  1897.  REISHAUS. — B.  z.  A., 
xxxi,  1898.  CAPELLINI. — K.  M.  f.  A.,  xxxix,  1901.  QUAGLINO  AND  GUAITA. — Ann.  di 
Ott.,  xiii,  1879.  FALCHI.— Ann.  di  Ott.,  xiv,  1885.  BENSON.— Ophth.  Rev.,  1887;  T.  O.  S., 
x,  1890.  GALLENGA. — Arch,  di  Ott.,  iii,  1896.  ROGMAN. — Ann.  d'Oc.,  cxxv,  1901. 
*  LAGRANGE. — Tumeurs  de  1'CEil,  Paris,  i,  1901. 

1  STOEWER,  A.  f.  O.,  xlviii,  i,  1899. 

'7 


258  THE    PATHOLOGY    OF   THE    EYE 


MYXOMA 

Adler,  in  1871,  reported  the  case  of  a  "  myxoma  "  of  the  otherwise 
normal  cornea  in  a  young  man  of  nineteen.  It  was  examined  by  \Vedl ; 
it  consisted  of  fibrous  tissue  with  numerous  cystic  spaces,  and  was 
covered  with  epithelium. 

Another  case  was  published  by  Mitvalsky,  of  a  woman,  aet.  26,  with 
a  polypoid  growth  from  the  centre  of  the  cornea.  The  eye  was  blind 
from  scrofulous  keratitis  in  infancy ;  it  had  become  staphylomatous, 
and  had  been  operated  on  by  simple  ablation.  The  tumour  wras  as 
large  as  a  cherry,  and  the  stalk  was  4  mm.  in  diameter.  It  had  been 
growing  for  two  years.  The  surface  was  smooth  and  glistening.  The 
epithelium  resembled  that  of  the  cornea ;  the  parenchyma  consisted  of 
typical  myxomatous  tissue  with  large  cystic  spaces,  the  older  ones 
being  surrounded  by  more  compact  tissue. 

Barrett,  in  1888,  reported  a  double  congenital  tumour  of  the  cornea 
and  sclera  as  a  myxo-fibroma,  but  the  diagnosis  is  doubtful. 

Simon  described  a  myxo-fibroma  in  a  man  aet.  61.  The  cornea 
had  ulcerated  six  years  before,  after  a  lime  burn,  and  had  been  treated 
by  Saemisch's  section.  The  eye  was  painful,  and  was  enucleated.  The 
tumour,  9  mm.  long  by  3*5  mm.  thick,  was  surrounded  by  corneal 
tissue  both  at  the  periphery  and  below.  It  was  covered  by  epithelium, 
which  was  thickened  so  that  there  were  thirty  layers  in  places.  The 
parenchyma  consisted  of  dense  cellular  fibrous  tissue  with  many  blood- 
vessels. On  the  nasal  side  there  was  a  small  elevation,  in  which  the 
fibrous  tissue  was  replaced  by  stellate  and  round-cells  embedded  in  a 
homogeneous  matrix.  On  the  temporal  side  there  was  a  hyaline  mem- 
brane under  the  corneal  tissue,  derived  probably  from  the  endothelial 
cells  of  Descemet's  membrane. 

Simon  regarded  this  tumour  as  a  "  scar-fibroma "  (Narbenfibrom) 
which  had  undergone  myxomatous  degeneration ;  and  this  is  probably 
the  explanation  of  all  these  myxomata. 

Whether  they  are  true  myxomata,  containing  mucin,  or  merely 
cedematous  connective-tissue  growths  has  not  been  settled  by  crucial 
chemical  tests. 

ADLER. — Wiener  med.  Woch.,  1871.  MITVALSKY. — A.  d'O.,  xiv,  1894.  BARRETT. — 
Australian  Med.  Jl.,  1888.  SIMON. — C.  f.  A.,  xvi,  1892. 


TERATOID  TUMOURS 

Dermoid  and  teratoid  tumours  which  are  strictly  limited  to  the 
cornea  are  of  extreme  rarity.  It  may  almost  be  doubted  whether  they 
occur  at  all. 

Fuchs  described  a  dermoid  in  a  boy  of  twelve,  occupying  the  outer 
half  of  the  right  cornea,  extending  from  the  centre  to  the  limbus,  but  not 
beyond  this.  It  consisted  chiefly  of  dilated  lymphatics  lying  in  connective 
tissue.  The  epithelium  covering  it  was  corneal,  not  epidermal.  The 


THE    CORNEA  259 

growth  contained  no  hairs  or  sebaceous  glands,  but  there  was  a  large 
acinotubular  gland  resembling  Krause's  glands. 

Bernheimer  reported  an  extraordinary  case  in  a  child  six  months 
old.  There  was  an  anterior  staphyloma,  almost  certainly  due  to  intra- 
uterine  perforating  ulcer.  The  pseudo-cornea  was  greatly  thickened, 
the  anterior  part  forming  a  derrnoid  tumour.  The  epithelium  was 
unequally  thickened,  horny  on  the  surface,  and  sho\ved  many  down- 
growths.  There  were  many  hairs,  with  hair-follicles  and  sebaceous 
glands.  The  ground  tissue  consisted  of  dense  connective  tissue,  con- 
taining capillaries,  and  fine  bands  and  groups  of  round-cells.  At  the 
periphery  the  fibrous  tissue  was  looser,  and  contained  masses  of  adipose 
tissue.  Descemet's  membrane  was  intact  except  at  one  spot,  where  it 
was  broken  and  the  ends  were  curled  up.  Adherent  to  it  was  the 
atrophic  iris,  with  its  retinal  pigment  layer. 

The  tumour  described  by  Cohn  was  of  the  teratoid  type.  The 
epithelium  was  like  that  of  the  conjunctiva,  possessing  goblet-cells  and 
no  horny  layer,  except  at  the  periphery.  Here  there  were  no  papillae, 
but  these  were  present  in  the  centre.  The  connective  tissue  contained 
many  glands  resembling  Krause's,  but  apparently  secreting  mucus  which 
stained  with  thionin.  There  were  also  islands  of  cartilage  and  fat,  as 
well  as  many  vessels  and  lymphocytes.  The  lamellae  were  mostly 
replaced  by  young  connective  tissue.  There  were  several  breaks  in 
Descemet's  membrane,  with  anterior  synechiae. 

FUCHS.— K.  M.  f.  A.,  xviii,  1880.  BERNHEIMER. — A.  f.  A.,  xviii,  1887.  COHX. — Inaug. 
Diss.,  Heidelberg,  1896. 


SARCOMA  AND  ENDOTHELIOMA 

Sarcoma  of  the  cornea  proper  is  extremely  rare. 

Rumschewitsch  describes  a  case  in  a  man  aet.  61,  who  had  lost 
the  sight  of  his  eye  after  a  blow  upon  the  head.  The  tumour  was 
mushroom  shaped,  the  pedicle  springing  from  the  cornea,  and  having 
no  conection  with  the  conjunctiva  ;  it  was  7*5  mm.  thick.  Bowman's 
membrane  was  intact  up  to  the  pedicle.  The  corneal  lamellae 
passed  into  the  connective-tissue  strands  of  the  pedicle,  which  con- 
tained many  blood-vessels.  The  tumour  itself  was  very  vascular,  with 
haemorrhages.  The  cells  were  chiefly  spindle  shaped,  with  very  little 
intercellular  substance,  but  there  were  many  round-cells,  which  were 
indistinguishable  from  leucocytes,  and  were  chiefly  aggregated  near  the 
capillaries.  The  growth  was  covered  by  epithelium,  which  was  broken 
in  places  by  haemorrhages. 

Blanquinque  describes  a  melano-sarcoma  in  a  woman  set.  60, 
which  had  been  noticed  first  twenty  years  previously  as  a  red  spot  near 
the  centre  of  the  cornea  ;  it  had  been  increasing  for  nine  years,  extending 
up  and  out  to  i  mm.  from  the  limbus.  It  was  the  size  of  a  pea,  greyish, 
smooth,  not  ulcerated,  firm,  painless.  The  tumour  was  shaved  off  by  a 
Graefe  knife.  It  was  examined  by  Malassez.  It  was  lobulated,  covered 
with  epithelium,  some  of  the  deeper  cells  of  which  were  pigmented. 
The  main  mass  consisted  of  cells  which  were  very  variable  in  size  and 


260 


THE    PATHOLOGY   OF   THE    EYE 


shape,  some  grouped  in  spherical  masses.  The  nuclei  were  masked  by 
small  yellowish-brown  "  granulations."  There  were  very  few  vessels 
and  no  haemorrhages. 

Chantiniere  reported  a  man  set.  33,  from  whom  a  small  tumour  was 
removed;  it  recurred  rapidly.  It  was  covered  by  normal  epithelium 
and  Bowman's  membrane,  which  was  perforated  at  several  places. 
Angular  cells  of  connective-tissue  origin  infiltrated  the  anterior  layers  of 
the  substantia  propria  and  passed  through  the  holes  in  Bowman's 
membrane.  There  were  very  few  vessels,  derived  from  a  leash  from  the 
conjunctiva. 

The  case  of  Donaldson,  examined  by  Treacher  Collins,  extended 
over  the  sclerotic  for  4  mm.,  and  is  therefore  a  doubtful  case.  It  was 


FIG.  179. — ALVEOLAR  SARCOMA  OF  CORNEA,      x   100. 
Donaldson  and  Treacher  Collins,  T.  O.  S.,  xv. 


made  up  of  groups  of  round-cells,  surrounded  by  fibrous  tissue  and 
elongated  cells,  and  was  diagnosed  as  an  alveolar  sarcoma  (Fig.  179). 

Gonin  reports  the  case  of  a  man,  aet.  32,  with  a  melanotic  (?) 
sarcoma  of  the  cornea  of  two  months'  growth.  It  was  removed,  after 
iridectomy,  by  a  Graefe  knife,  and  the  base  cauterised.  There  was  no 
recurrence  sixteen  months  later.  It  consisted  of  fusiform  cells  of 
medium  size,  with  little  intercellular  substance ;  there  were  patches  of 
degeneration,  and  signs  of  alveolation.  The  pigmentation  was  probably 
due  to  haemorrhage,  as  the  growth  had  been  previously  incised ;  more- 
over scattered  haemorrhages  were  present.  The  pigment  did  not  give 
any  reaction  for  iron. 

Rogman  relates  the  case  of  a  woman  of  sixty-five  with  the  appearance 
of  a  small  prolapsed  iris.  On  removal  it  was  found  to  consist  of  round 


THE    CORNEA 


261 


and  spindle-shaped  cells,  with  signs  of  an  alveolar  arrangement ;  some 
were  densely  pigmented. 

Rumschewitsch's  second  case  occurred  in  a  girl,  set.  14,  with 
advanced  trachoma,  and  was  doubtless  pannus  with  an  unusual  degree 
of  hyperplasia. 

v.  Michel  records  metastatic  deposits  of  melanotic  sarcoma  in  the 
cornea,  accompanying  an  episcleral  growth. 

Fumagalli  records  a  primary  sarcoma  in  a  woman  of  fifty-two,  whose 
cornea  was  injured  by  a  finger-nail  seven  years  before.  It  had  the 
structure  of  a  perivascular  sarcoma,  growing  from  new-formed  blood- 
vessels. 

None  of  these  cases  are  above  suspicion  as  to  diagnosis.  The  evas- 
cular  fibrous  stroma  of  the  cornea,  like  tendons  and  aponeuroses,  might 
be  expected  to  enjoy  relative  immunity  from  malignant  growths, 
whilst  it  is  always  impossible  to  exclude  invasion  from  the  periphery, 


FIG.  180. — ENDOTHELIOMA  OF  THE  CORNEA,      x   12. 

Slowly    growing,    frequently    recurrent    growth    of    cornea,    in    an    adult  (see 
T.  O.  S.,  xxiii,  1903,  Sinclair  and  Parsons).     Note  the  alveolar  arrangement. 


from  which  the  blood-supply  must  necessarily  be  derived.  The  resem- 
blance of  embryonic  connective  tissue  in  inflammatory  granulations  to 
sarcoma  and  the  loss  of  the  iron  reaction  in  old  haemorrhagic  pig- 
mentation form  insuperable  barriers  to  certitude  of  diagnosis  in  the 
present  state  of  knowledge.  Nevertheless  malignant  proliferation  of 
the  fixed  corneal  corpuscles  cannot  be  definitely  eliminated.  Should  it 
occur,  the  disposition  of  the  corneal  lamellae  might  be  expected  to  give 
rise  to  a  quasi-alveolar  arrangement. 

Donaldson's  and  Fumagalli's  cases  most  nearly  resemble  the  one 
which  I  have  described  as  an  endothelioma  of  the  cornea.  Transverse 
sections  of  the  growth  were  plano-convex  (Fig.  180).  The  convex 
surface  was  covered  with  epithelium,  which  was  flattened,  varied 
greatly  in  thickness,  and  was  absent  near  the  periphery  on  one  side. 
The  growth  consisted  of  masses  of  epithelioid  cells  arranged  in  an 
alveolar  manner,  enclosed  in  capsules  of  spindle-celled  fibrous  tissue 
(Fig.  181).  This  tissue  stained  red  with  van  Gieson,  and  fibrillse  passed 
between  the  outer  cells  of  the  masses,  but  the  larger  central  parts  were 
devoid  of  any  definite  intercellular  stroma. 

The  epithelioid  cells  varied  greatly  in  size  and  shape ;  many  showed 


262 


THE    PATHOLOGY    OF   THE    EYE 


karyokinetic  phases,  others  atypical  nuclear  changes.  The  aggregations 
also  varied  in  size.  They  were  mostly  oval,  and  the  smaller  ones 
invaded  the  epithelium  in  places,  recalling  the  conditions  found  in  con- 
genital naevi  (r.  p.  127). 

There  can  be  little  doubt  that  this  growth  was  an  endothelioma,  and 
that  it  originated  in  the  limbus,  and  is  not  a  true  autochthonous  corneal 
growth.  There  are  faint  indications  of  debris  of  red  corpuscles  in  a  few 


FIG.  181. — ENDOTHELIOMA  OF  THE  CORNEA,      x   120. 
From  the  same  specimen  as  Fig.  180. 

of  the  alveoli,  and  this  points  to  blood-vascular  endothelium  as  the 
origin  of  the  cells. 

RUMSCHEWITSCH. — A.  f.  A.,  xxiii,  1,891.  BLANQUINQUE. — Rec.  d'O.,  1892.  CHATINIERE. 
— See  LAGRANGE.  DONALDSON. — T.  O.  S.,  xv,  1895.  GONIN. — Ziegler's  Beitrage,  xxiv, 
1898.  ROGMAN. — Ann.  d'Oc.,  1901.  RUMSCHEWITSCH. — A.  f.  A.,  xxxi,  1893.  v.  MICHEL. — 
Beitr.  z.  Onkol.  d.  Auges.,  Wiirzburg,  1899.  FUMAGALLI. — La  Clin.  Oc.,  1902  ;  K.  M.  f.  A., 
xl,  1902.  *  SINCLAIR  AND  PARSONS. — T.  O.  S.,  xxiii,  1903.  *  LAGRANGE. — Tumeurs  de 
1'CEil,  i,  Paris,  1901. 


EPITHELIOMA 

Most  of  the  cases  of  so-called  epithelioma  of  the  cornea  are  really 
growths  starting  in  the  limbus  at  the  site  where  the  conjunctival 
epithelium  changes  into  corneal.  Such  sites  form  the  commonest  places 
at  which  epitheliomata  develop  in  the  body,  e.g.  the  edge  of  the  lid,  lip, 
anus,  etc.  To  this  group  belong  the  cases  of  Adams,  Colsman, 
Goldzieher,  Manfredi,  Manz,  and  others.  I  have  examined  the  sections 
of  the  case  described  by  Lawford,  and  there  can  be  no  doubt  that  this 
was  a  case  of  Mooren's  ulcer,  and  therefore  not  an  ordinary  epithelioma. 


THE    CORNEA  263 

Cases  of  primary  epithelioma  of  the  cornea  itself  are  excessively  rare. 
Only  six  cases  can  be  found  in  the  literature  in  which  the  accuracy  of 
the  diagnosis  is  probable. 

A  patient  of  Galezowski's  had  a  small  growth  in  the  centre  of  the 
cornea,  which  was  removed,  and  examined  by  Ranvier  and  Cornil,  who 
reported  that  it  was  a  carcinoma,  limited  to  the  superficial  layers,  leaving 
the  substantia  propria  quite  healthy. 

Dolgenkow  describes  a  large,  hard,  pale  red,  lobulated  tumour  of  the 
cornea,  which  developed  during  eighteen  months.  It  was  mushroom 
shaped,  the  pedicle  being  short  and  thick,  and  growing  only  from  the 
cornea.  The  sclera  and  conjunctiva  were  normal  apart  from  round- 
celled  infiltration. 

Sgrosso  describes  the  microscopical  features  of  two  small  tumours 
shaved  off  from  the  cornea.  The  first  was  separated  i  mm.  from  the 
limbus ;  it  consisted  of  polygonal  cells  with  large  nuclei,  forming  cones 
which  penetrated  into  the  substantia  propria,  Bowman's  membrane 
being  destroyed.  The  whole  of  the  tumour  was  removed.  In  the  second 
case,  the  epithelium  had  proliferated  downwards  slightly  into  masses  of 
granulation  tissue,  which  replaced  Bowman's  membrane  ;  the  lamellae 
were  intact.  The  drawing  gives  the  impression  that  there  was  a  distinct 
basement  membrane,  the  growth  being  probably  a  benign  hyperplasia. 

Snellen  Jr.  reports  the  case  of  an  elderly  man  who  had  been  in  the 
East  Indies,  who  developed  a  true  cornea!  epithelioma  in  connection 
with  a  pterygium.  This  is  the  best  example  of  an  epithelioma,  but  its 
association  with  a  pterygium  throws  some  doubt  on  its  corneal  origin. 
It  invaded  the  substantia  propria,  extending  under  Bowman's  membrane 
and  the  superficial  epithelium,  both  of  which  were  intact  over  the  greater 
area  of  the  cornea.  It  did  not  invade  the  anterior  chamber  or  the 
sclerotic,  and  such  changes  as  were  present  in  the  uveal  tract  and  retina 
were  inflammatory.  There  can  be  no  doubt  about  the  epitheliomatous 
nature  of  the  growth. 

Nuel  refers  to  a  similar  case  in  an  East  Indian,  and  to  another  of 
Steiner's,  but  gives  no  details. 

Alfieri's  case  is  the  most  fully  reported.  The  growth  developed  in 
the  centre  of  the  cornea,  and  had  no  communication  with  the  limbus. 
It  occurred  in  a  man,  set.  70,  who  had  been  struck  in  the  right  eye  by  a 
branch  twenty  years  before  ;  the  cornea  became  opaque.  A  few  months 
before  being  seen  a  red  excrescence  appeared  upon  the  scar,  finely 
lobulated,  umbilicated,  and  separated  from  the  limbus  by  a  ring  of  opaque 
cornea.  The  eye  was  enucleated,  and  the  growth  found  to  consist  of 
epithelial  cells,  flattened  near  the  surface,  rounder  and  more  cubical  in 
the  deeper  layers.  The  central  depression  was  probably  due  to 
necrosis. 

Aubineau  observed  a  corneal  tumour  in  a  man  set.  65.  It  was  white, 
flat  (2 — 3  mm.  thick),  in  the  lower  and  outer  part  of  the  cornea,  quite 
separated  from  the  limbus.  It  was  described  as  an  "  epitheliome 
lobule  corne  et  muqueux." 

The  cases,  therefore,  of  true  corneal  epitheliomata  are  extremely 
rare,  and  are  all  open  to  more  or  less  doubt.  It  seems  probable,  how- 
ever, that  the  corneal  epithelium  is  capable  of  malignant  proliferation, 


264  THE    PATHOLOGY    OF   THE    EYE 

and  that  it  has  but  slight  tendency  to  extend  deeply  (Lagrange).  It  is 
rare  for  epibulbar  growths  to  invade  the  interior  of  the  eye  ;  epithe- 
lioma  of  the  cornea  apparently  never  does.  The  substantia  propria 
offers  some  resistance  to  the  invasion,  setting  up  a  barrier  of  embryonic 
connective  tissue  around  the  epithelial  cells.  The  fact  that  the  canal  of 
Schlemm  and  the  anterior  perforating  vessels  lie  under  the  conjunctiva 
accounts  for  the  fact  that  the  growth  never  becomes  intra-bulbar ;  added 
to  this  is  the  fact  of  the  intra-ocular  pressure  which  prevents  the 
growth  from  bursting  through  elsewhere.  Like  all  tumours,  they  grow 
in  the  direction  of  least  resistance,  which  in  this  case  is  forwards  and 
peripherally. 

It  is  extremely  noteworthy  that  no  epithelioma  of  the  uninjured 
cornea  has  ever  been  observed. 

ADAMS. — T.  O.  S.,  ii,  1882.  COLSMAN. — K.  M.  f.  A.,  vii,  1869.  GOLDZIEHER. — In 
Nagel's  Jahresb.,  1875.  MANFREDI. — Riv.  Clin.,  1870.  MANZ. — A.  f.  O.,  xvii,  2,  1871. 
LAWFORD. — R.  L.  O.  H.  Rep.,  xii,  3,  1889.  GALEZOWSKI. — Traite  des  Maladies  des  Yeux, 
i,  p.  312,  1870.  DOLGENKOW. — West.  Opht.,  1885  (see  LAGRANGE).  SGROSSO. — Ann.  di  Ott., 
xxi,  1892.  SNELLEN,  JR. — 6me  Sess.  semestrielle  d'Opht.,  Utrecht,  1894.  NUEL. — In 
NORRIS  AND  OLIVER'S  System,  iv,  London,  1900.  ALFIERI. — Arch,  di  Ott.,  v.  AUBINEAU. — 
Soc.  d'Opht.  de  Paris,  1898 ;  in  Nagel's  Jahresb.,  1898.  *  LAGRANGE. — Tumeurs  de  1'CEil, 
i,  Paris,  1901.  BAAS. — Z.  f.  A.,  x,  1903. 


GENERAL  REMARKS  UPON  CORNEAL  TUMOURS 

A  review  of  the  recorded  cases  of  corneal  tumours  leaves  one  in  great 
doubt  as  to  their  true  status.  No  sharp  line  can  be  drawn  between 
purely  inflammatory  conditions  and  many  so-called  growths.  There  is 
an  even  gradation  from  the  simple  corneal  scar  to  the  myxoma  on  the 
one  hand  and  the  papilloma  on  the  other,  the  horn  occupying  an  inter- 
mediate position.  This  may  be  diagrammatically  represented  thus — 

Corneal  wound 


Superficial  Perforated 

Scar —  — I —  — Pseudo-cornea 

Scar  fibroma 


it  ii 

'?  Papilloma  ?  Sarcoma  Pseudo-cornea  Simple 

Myxo-fibroma  with  Granuloma 

papillae 
and  corneous 
Myxoma          epithelium  ?  Cicatrix 

|  Horn 

?  Papilloma 

Whether  the  true  papillomata  invariably  develop  thus  or  may  arise 
de  novo  must  be  left  to  future  research  to  decide.  And  further,  whether 
any  of  these  conditions  are  truly  corneal  in  origin  is  open  to  doubt. 
Even  inflammation  in  the  absence  of  blood-vessels  is  unknown,  and  only 
epithelium  is  capable  of  repair  without  their  agency,  direct  or  indirect. 


THE    CORNEA  265 

The  same  applies  with  equal  force  to  the  new  growths,  both  benign  and 
malignant,  for  all  are  vascular,  though  in  varying  degree,  and  derive 
their  vessels  from  the  limbus.  Most  doubtful  of  all  are  the  malignant 
growths,  especially  the  epitheliomata  and  the  endothelial  type  of  sarco- 
mata. The  proclivity  of  the  former  to  arise  at  sites  where  the  epithe- 
lium changes  in  character  is  well  known,  though  their  occurrence  else- 
where is  an  established  fact.  As  regards  the  endotheliomata,  there  are 
no  vessels  in  the  cornea,  and  the  only  endothelium  is  around  the  nerves. 
The  endothelioma  of  the  cornea  which  I  have  described  undoubtedly 
originated  in  the  limbus,  and  the  case  would  seem  to  be  unique.  As  to 
the  embryonic  spindle-celled  type  of  sarcoma,  it  may  be  doubted  whether 
some  of  them  are  not  simple  granulomata  (granulation  tissue). 


CHAPTER    IV 
THE    SCLEROTIC 

THE  NORMAL  SCLEROTIC 

THE  sclerotic  is  the  main  supporting  envelope  of  the  eye.  It  is 
thickest  at  the  posterior  part,  especially  around  the  optic  nerve 
(1*0 — 1'2  mm.)  ;  and  thinnest  at  the  equator,  where  it  is  covered  by  the 
muscles  (0*3  mm.).  More  anteriorly  it  is  reinforced  by  the  expansions 
of  the  tendons  of  the  recti  and  again  becomes  rather  thicker 
(o'4 — o'5  mm.). 

As  mentioned  before,  it  overlaps  the  cornea  like  the  rim  of  a  watch- 
glass.  Just  behind  this  it  is  thinned  by  an  internal  furrow,  sulcus  sclerce 
interims  (Schwalbe),  which  is  spanned  by  the  ligmncntuuipectinatmn  iridis, 
and  has  the  canal  of  Schlemm  at  its  apex. 

The  sclerotic  consists  of  fibrils  of  connective  tissue  united  into 
bundles,  resembling  the  lamellas  of  the  cornea,  but  less  regular  and 
closer  packed.  The  bundles  run  chiefly  in  two  directions,  meridionally, 
i.  e.  from  before  backwards,  and  equatorially,  i.  e.  concentric  with  the 
margin  of  the  cornea.  But  there  are  also  many  oblique  bundles,  and 
the  arrangement  is  much  interrupted  by  the  entrance  of  the  tendons  of 
the  recti  and  the  obliques.  Thus  in  front  of  the  equator  most  of  the 
superficial  bundles  are  meridional,  the  deep  equatorial ;  the  superficial 
and  middle  ones  run  into  the  cornea;  the  anterior  bundles  are  finer, 
firmer,  and  more  closely  plaited.  The  recti  tendons  reinforce  the 
meridional  fibres.  Between  the  muscles,  the  external  bundles  are  mostly 
equatorial,  the  internal  meridional.  The  posterior  calotte  is  more  com- 
plex, more  of  the  fibres  being  oblique,  and  fewer  equatorial.  The  oblique 
tendons  further  reinforce  the  oblique  and  meridional  fibres  (Ischreyt). 

Mingled  with  the  white  connective-tissue  fibrils  are  an  immense 
number  of  extremely  fine  elastic  ones,  the  general  arrangement  of  which 
can  be  traced  by  special  stains  (acid  orcein  or  Weigert's  elastic-tissue 
stain)  (Sattler,  Treacher  Collins,  Ischreyt,  and  others).  These  are  fewer 
in  youth.  They  run  for  the  most  part  as  wavy  fibrils  in  the  same  direction 
as  the  white  fibres.  At  the  limbus  they  circle  round  the  cornea,  so  that 
they  appear  as  minute  dots  in  antero-posterior  sections.  The  outer 
layers  contain  more  elastic  fibres  than  the  inner,  and  they  are  more 
numerous  posteriorly  than  anteriorly  (Treacher  Collins).  According  to 
Ischreyt,  they  increase  from  without  inwards  posteriorly,  whilst  at  the 
equator  they  are  richest  on  the  surface,  rather  less  marked  in  the  inner 
layer,  and  scanty  in  the  middle  layers.  They  form  a  ring  around 


THE    SCLEROTIC  267 

Schlemm's  canal,  and  are  cut  transversely  here  in  meridional  sections. 
They  also  form  a  ring  around  the  optic  nerve,  and  the  lamina  cribrosa  is 
full  of  them,  though  they  are  absent  here  in  the  foetus  (Kiribuchi). 

Posteriorly  the  outer  layers  of  the  sclerotic  are  continuous  with  the 
dural  sheath  of  the  optic  nerve,  whilst  many  of  the  inner  layers,  including 
a  particularly  large  number  of  elastic  fibres,  are  carried  across  the  nerve 
as  it  lies  in  the  foramen  scleras,  and  form  the  lamina  cribrosa. 

Between  the  bundles  of  fibres  are  lymph-spaces,  containing  fixed 
connective-tissue  cells,  though  these  are  far  less  numerous  than  in  the 
cornea.  There  are  not  infrequently  scattered  pigment-cells,  especially 
in  the  inner  layers,  and  others  often  accompany  the  perforating  vessels 
and  nerves.  Occasionally  patches  of  pigment  occur  (melanosis  sclerae, 
Hirschberg).  These  are  commonest  in  the  episcleral  tissue  (cf.  Treacher 
Collins),  but  are  also  found  in  the  true  sclera,  thus  approximating  the 
condition  often  found  in  lower  animals.  They  are  usually  associated 
with  abnormally  dark  pigmentation  of  the  uveal  tract,  the  disc,  and 
other  parts  of  the  body,  as  well  as  with  pigmented  moles. 

The  inner  surface  of  the  sclerotic  is  normally  pigmented,  and  forms 
the  lamina  fusca.  It  is  united  by  fibrils  of  pigmented  connective  tissue 
with  the  choroid,  and  is  lined  by  endothelial  cells,  forming  the  external 
wall  of  the  supra-choroidal  lymph-space.  The  outer  surface  of  the 
sclerotic  is  also  covered  with  a  single  layer  of  endothelial  cells,  forming 
the  ocular  wall  of  Tenon's  capsule.  The  endothelial  covering  is  re- 
flected over  all  the  vessels,  nerves,  and  muscles  which  pass  across  the 
space.  Thus  they  all  invaginate  the  space,  and  never  actually  enter  it. 

The  proper  blood-vessels  and  nerves  of  the  sclerotic  are  few  in 
number.  Arteries  are  given  off  from  the  short  posterior  and  the 
anterior  ciliaries.  The  posterior  ciliary  veins — smaller  than  the  cor- 
responding arteries — are  derived  entirely  from  the  sclerotic ;  the  anterior 
ciliary  veins  are  only  in  part  derived  from  the  sclerotic.  Branches  of 
the  posterior  ciliary  arteries  anastomose  with  branches  of  the  central 
retinal  vessels,  and  form  an  anastomotic  ring,  situated  in  the  sclerotic 
around  the  optic  nerve  (Circulns  arteriosus  of  Zinn).  This  is  important 
as  being  an  indirect  anastomosis  between  the  choroidal  and  retinal 
circulations  (see  Parsons).  Some  of  the  equatorial  scleral  veins  open 
into  the  venae  vorticosae.  A  scanty  nerve-supply  is  derived  from  the 
posterior  ciliary  nerves,  as  they  run  between  the  sclerotic  and  choroid. 
Their  ultimate  distribution  has  been  investigated  by  the  Golgi  method 
by  Bach. 

SATTLER. — B.  d.  o.  G.,  1896,  1897.  TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xv,  1899. 
ISCHREYT. — A.  f.  O.,  xlviii,  3,  1899 ;  A.  f.  O.,  xlix,  3,  1900 ;  K.  M.  f.  A.,  xl,  1902.  BIETTI  — 
Arch,  di  Ott.,  iv,  1897  ;  A.  f.  A.,  xxxix,  1899.  HIRSCHBERG. — A.  f.  O.,  xxix,  i,  1883.  STUTZER. 
— A.  f.  O.,xlv,  2,  1898.  KIRIBUCHI. — A.f.  A.,  xxxviii,  1899.  PROKOPENKO. — A.  f.  O.,  Iv,  i, 
1902.  TREACHER  COLLINS. — T.  O.  S.,  xiv,  1894.  PARSONS. — The  Ocular  Circulation, 
London,  1903.  BACH. — A.  f.  A.,  xxxiii,  1896. 


WOUNDS   AND    INJURIES 

Most  injuries  of  the  sclerotic  are  perforating  wounds  and  ruptures. 
In  all  these  cases  the  injury  is  complicated  by  wounding  of  the  con- 


268  THE    PATHOLOGY   OF   THE    EYE 

junctiva,  episclera,  uveal  tract,  and  retina  in  varying  degree.  Ruptures 
may  indeed  be  subconjunctival,  but  wounds  invariably  injure  the  con- 
junctiva and  episclera  if  from  without,  or  the  retina  and  choroid  if  from 
within.  Hence  in  all  cases  some  highly  vascular  tissue  is  affected  in 
conjunction  with  the  sclerotic.  This  is  of  the  utmost  importance,  since 
it  has  been  found  by  pathological  observation  and  by  experiment  that 
repair  takes  place  almost  entirely  through  the  agency  of  these  vascular 
tunics.  This  was  indicated  even  in  the  earliest  experiments  by  Lju- 
binsky  (1867).  Roth  thought  the  cells  were  derived  from  the  vitreous 
and  sclerotic,  the  retina  and  choroid  being  inactive.  Miyshita  ascribed 
the  healing  of  a  scleral  wound  to  the  sclerotic  alone,  Baquis  to  sclerotic 
and  episclera.  Tepljaschin  agreed  in  the  main  with  Ljubinsky,  but 
attributed  a  minor  function  to  the  vitreous  and  sclerotic. 

More  exhaustive  and  more  recent  experiments  and  observations 
have  been  carried  out  by  Franke  (1895),  Kriickmann  (1896),  Stoewer 
(1898),  and  myself  (1901 — 2).  Franke  and  Stoewer  operated  upon 
rabbits,  the  former  examining  wounds  of  a  duration  of  four,  eight, 
twelve,  twenty-four  hours,  and  every  other  day  up  to  eighteen  days. 
Kriickmann  paid  most  attention  to  the  changes  during  the  first  twenty- 
four  hours,  but  also  continued  the  investigation  up  to  120  days;  he 
experimented  upon  guinea-pigs,  rats,  cats,  and  dogs,  as  well  as  rabbits. 
I  myself  operated  upon  monkeys,  the  wounds  being  perforating  wounds 
of  the  posterior  part  of  the  ciliary  region  from  without  in,  and  injuries 
or  perforating  wounds  of  the  fundus  from  within  out. 

According  to  Kriickmann,  the  invasion  of  the  wound  and  neighbour- 
ing parts  by  leucocytes  is  the  prominent  feature  four  to  six  hours  after 
the  operation.  These  leucocytes  are  poured  forth  from  all  the  blood- 
vessels available,  viz.  those  of  the  episclera,  choroid,  and  such  sclerotic 
vessels  as  are  to  be  found.  They  are  carried  from  all  sides  into  the 
wound,  which  they  block,  the  groups  being  thickest  along  the  edges. 
They  penetrate  into  the  dilated  lymphatic  channels  between  the  scleral 
lamellae  ("  Infiltrations-scleritis  "  of  Alt).  The  meshes  of  the  supra- 
choroidea  are  also  packed  with  them.  Their  function  is  largely  a 
phagocytic  one,  directed  to  the  removal  of  the  parts  injured  beyond 
repair.  The  edges  of  the  wound  become  smooth  and  glazed,  so  that 
the  process  differs  in  no  essential  from  that  which  occurs  in  other  parts 
of  the  body.  In  the  course  of  the  second  day  the  leucocytes  begin  to 
disappear,  their  duty  as  scavengers  having  been  accomplished. 

Franke  describes  the  new  formation  of  round-  and  spindle-shaped 
cells  during  this  period  by  a  process  of  amitotic  division.  The  need 
for  rapid  increase  of  cells  in  all  acute  inflammatory  processes  results  in 
division  by  fission,  gemmation,  etc.,  ordinary  karyokinesis  being  appa- 
rently too  slow.  This  is  seen  par  excellence  in  the  cornea.  It  is  not 
surprising  that  some  increase  of  the  cells  present  should  occur  at  this 
early  stage,  but  it  is  probable  that  most  of  them  are  leucocytes  (Kriick- 
mann, Stoewer),  and  that  the  process  described  by  Franke  plays  a  very 
subsidiary  part. 

Franke  observed  the  evidences  of  karyokinesis  after  forty-three  hours, 
which  agrees  well  with  the  time  assigned  by  Kriickmann  for  the  com- 
mencement of  the  second  stage,  viz.  the  process  of  repair.  By  this 


THE    SCLEROTIC  269 

time  the  detritus  and  perhaps  much  of  the  fibrinous  coagulum  which 
formed  a  large  part  of  the  inflammatory  exudate  have  been  removed  by 
the  agency  of  the  leucocytes,  and  these  themselves  have  in  turn  largely 
disappeared.  It  is  now  that  the  activity  of  the  fixed  tissue  elements 
forms  a  leading  feature,  and  as  in  other  parts  of  the  body,  the  blood- 
vessels are  the  most  important.  In  the  episcleral  tissue  and  conjunc- 
tiva, in  the  interstices  of  the  neighbouring  muscle-fibres,  and  in  the 
choroid,  many  cells  are  seen  dividing  by  mitosis,  but  especially  those 
belonging  to  the  adventitia  of  the  blood-vessels.  These  (probably 
including  the  plasma-cells)  proliferate  rapidly,  forming  spindle-shaped 
cells,  i.  e.  embryonic  fibrous  tissue,  which  invade  the  wound  area, 
accompanied  by  new-formed  capillaries.  Many  types  of  cells  are  seen  in 
many  stages  of  proliferation,  but  besides  those  already  mentioned  endo- 
thelial  cells  are  very  prominent.  The  scanty  scleral  corpuscles  are  not 
inactive,  but  also  proliferate.  They  do  not  appear,  however,  to 'invade 
the  wound  area  until  a  later  period.  The  leucocytes  play  no  part  in  the 
process  of  repair.  The  vitreous  has  a  purely  passive  part  in  the  process, 
except  that  it  becomes  fibrillated  (Franke).  The  retina  is  also  passive, 
becoming  glued  down  to  the  choroid  and  locally  degenerated.  The 
retinal  vessels  probably  play  a  small  part  in  common  with  those  of  the 
choroid.  (See  '  Wounds  of  the  Retina.') 

Duffing  examined  an  eye  microscopically  four  weeks  after  a  double 
perforating  wound  of  the  sclerotic  by  a  small  saw.  He  found  that  the 
fibres  of  the  scar  now  had  the  same  direction  as  those  of  the  normal 
sclera,  and  passed  imperceptibly  into  the  surrounding  normal  tissue. 
This  result  was  confirmed  by  Franke's  experiments  on  rabbits.  It  is  at 
this  stage  in  all  probability  that  the  normal  sclerotic  corpuscles  manifest 
their  influence.  They  probably  reproduce  themselves  slowly,  and  par- 
tially replace  the  scar  tissue.  It  is  not  unlikely,  too,  that  they  influence 
the  polarity  and  character  of  the  newly  formed  fibrous  tissue,  tending 
to  mould  the  new  cells  gradually  to  their  own  type.  Such  an  "  infective  " 
influence  of  one  cell  upon  its  neighbours  is  not  uncommon  in  many 
pathological  conditions  (e.g.  new  growths),  but  where  the  injured 
normal  cells  are  of  a  high  degree  of  differentiation  the  process  usually 
stops  short  at  a  lower  grade,  as  is  seen  in  the  latest  stages  of  scars  in 
the  cornea.  These  become  more  allied  to  sclerotic  cells  than  to  corneal 
corpuscles,  possibly  a  form  of  atavism.  In  the  case  of  the  sclerotic  itself 
the  lowly  grade  of  cell  is  more  readily  approximated  by  the  new-formed 
corpuscles.  The  tissue,  however,  though  much  resembling  the  normal 
sclerotic,  is  never  absolutely  normal ;  the  fibrils  lie  much  more  closely 
packed  and  are  not  so  sharply  divided  into  bundles,  and,  as  in  scar 
tissue  generally,  the  typical  lymph-spaces  are  absent. 

Kriickmann  draws  a  distinction  between  the  more  cellular  "  scar 
tissue  "  (Narbengewebe)  on  the  inner  and  outer  surfaces  and  the  "  com- 
pensatory or  substitutive  tissue  "  (Ersatzgewebe)  interposed  between  the 
lips  of  the  scleral  wound. 

I  have  examined  a  large  number  of  human  eyes  with  perforating 
wounds,  and  have  given  detailed  descriptions  of  three  cases,  four,  eight, 
and  nineteen  days  respectively  after  the  receipt  of  the  injury.  Besides 
the  length  of  time  there  are  other  factors  which  have  to  be  taken  into 


270  THE    PATHOLOGY    OF   THE    EYE 

consideration.  Experimental  lesions  are  clean  cut  and  aseptic;  injuries 
and  ruptures  are  often  ragged,  and  in  nearly  all  cases  which  reach  the 
pathological  laboratory  they  either  are  in  a  very  early  stage  or  are  septic. 
In  these  there  is  very  often  little  or  no  attempt  at  repair. 

LJUBINSKY. — A.  f.  O.,  xiii,  2,  1867.  ROTH. — Virchow's  Archiv,  Iv.  MIYSHITA. — Inaug. 
Diss.,  Wiirzburg,  1888.  BAQUIS. — Ziegler's  Beitrage,  iv.  TEPLJASCHIN. — A.  f.  A.,  xxviii, 
1894.  FRANKE. — A.  f.  O.,  xli,  3,  1895.  KRUCKMANN. — A  f.  O.,  xlii,  4,  1896.  STOEWER. — 
A.  f.  O.,  xlvi,  4,  1898.  PARSONS. — R.  L.  O.  H.  Rep.,  xv,  3,  1903.  DUFFING. — A.  f.  O.,  xl, 
2,  1894.  MELLER. — A.  f.  A.,  xliii,  i,  1901. 


INFLAMMATION 

Inflammation  of  the  sclerotic  is  one  of  the  rarer  affections  of  the  eye, 
and  is  always  limited  in  the  ordinary  types  to  the  anterior  segment 
between  the  margin  of  the  cornea  and  the  equator.  It  is  impossible, 
pathologically,  to  draw  any  hard  and  fast  line  between  the  deeper  forms 
of  conjunctivitis,  or  episcleritis,  and  true  inflammation  of  the  sclerotic 
itself,  orscleritis.  In  the  very  limited  number  of  cases  which  have  been 
examined  microscopically  the  general  type  of  inflammation  has  been 
characteristic,  but  the  relative  extent  has  varied  considerably  and 
apparently  out  of  all  proportion  to  the  clinical  severity.  There  are  also 
differences  in  detail  which  make  any  pathological  classification  at 
present  uncertain  and  incomplete.  Even  clinically  episcleritis  merges 
into  scleritis,  and  the  latter,  though  usually  nodular  like  the  former,  is 
invariably  more  diffuse,  and  in  rare  cases  invades  the  circumcorneal 
area.  The  superficial  and  deep  forms  will  be  described  separately, 
though  it  is  important  to  remember  that  no  accurate  line  of  demarca- 
tion can  be  drawn  between  them  pathologically  any  more  than 
clinically. 

EPISCLERITIS 

In  episcleritis  a  circumscribed  nodule,  which  may  be  as  large  as  a 
lentil,  is  formed.  It  is  hard,  immovable,  and  very  sensitive  to  the 
touch,  the  injected  conjunctiva  moving  freely  over  it.  It  is  traversed 
by  the  deeper  episcleral  vessels,  and  therefore  appears  violet  in  colour. 
It  is  extremely  chronic,  often  occurs  in  other  regions  of  the  circum- 
corneal zone,  never  ulcerates,  and  may  be  entirely  absorbed,  but  more 
frequently  leaves  a  slate-coloured  scar  behind,  to  which  the  conjunctiva 
is  adherent.  The  cornea  and  uveal  tract  rarely  participate  in  the  in- 
flammation. 

Microscopically  the  nodule  is  seen  to  be  caused  by  an  inflammatory 
round-celled  infiltration,  which  chiefly  involves  the  deep  layers  of  the 
episclera,  but  also  invades  the  superficial  laminae  of  the  sclerotic,  which 
are  separated  by  oedema,  the  lymphocytes  lying  in  rows  or  in  spindle- 
shaped  masses  between  them.  The  conjunctiva  is  also  infiltrated, 
mostly  in  the  subepithelial  layers,  the  middle  layers  being  least  affected 
(Schirmer).  The  lymphocytes  are  also  very  numerous  around  the 
blood-vessels,  which  are  widely  dilated  and  filled  with  blood.  Extrava- 


THE    SCLEROTIC  271 

sations  of  blood  are  also  sometimes  present  (Uhthoff,  Schirmer).  The 
lymphatics  are  also  extremely  dilated,  especially  in  the  superficial  layers. 
Their  endothelial  linings  are  intact,  and  they  contain  a  fine  granular 
coagulum  in  their  lumina.  The  cedematous  exudates  not  infrequently 
coagulate,  forming  networks  of  fibrin  with  entangled  leucocytes.  The 
lymphocytes  are  often  very  thickly  packed,  and  make  up  the  greater 
part  of  the  nodule.  The  fixed  connective-tissue  cells  do  not  apparently 
proliferate  (Schirmer). 

All  these  changes  may  completely  disappear,  though  vascular  con- 
gestion often  persists  for  a  long  time.  On  the  other  hand,  some  of  the 
superficial  scleral  lamellae  usually  necrose,  though  to  only  a  very  limited 
extent,  a  slight  thinning  of  the  sclerotic  being  the  result  (Wedl  and 
Bock). 

Episcleritis  periodica  fug-ax,  first  described  as  subconjunctivitis  by 
v.  Graefe,  and  later  by  Hutchinson,  Nettleship,  Fuchs,  and  others,  has 
not  been  examined  microscopically. 


SCLERITIS 

In  the  deeper  forms  of  scleritis,  which  are  much  rarer,  there  are  also 
nodules,  but  these  are  usually  less  circumscribed.  The  swelling  is  at 
first  dark  red  or  bluish,  later  it  becomes  pale  violet  and  semi- 
transparent,  like  porcelain.  It  may  extend  entirely  round  the  cornea. 
The  condition  differs  from  episcleritis  in  that  the  cornea  and  uveal 
tract  are  invariably  involved,  but  whether  primarily  or  secondarily  is 
uncertain  (see  "  Annular  Scleritis").  There  is  no  ulceration,  but  much 
absorption,  so  that  the  sclerotic  is  thinned,  a  dark  purple  cicatrix  being 
formed,  which  is  often  unable  to  resist  the  intra-ocular  pressure,  so  that 
ectasia  follows.  Young  adults  generally  suffer,  and  both  eyes  are 
commonly  affected.  In  many  cases  of  diffuse  deep  scleritis  hard  whitish 
nodules  develop  in  the  inflamed  zone.  They  are  the  size  of  a  pin's 
head,  and  lie  beneath  the  conjunctiva,  all  at  much  the  same  distance 
from  the  corneal  margin  (Fuchs).  They  disappear  without  disinte- 
grating. 

Microscopically  the  typical  features  of  episcleritis  are  often  present 
in  addition  to  the  deep  scleritis  (Kostenitsch).  The  sclerotic  is, 
however,  most  infiltrated  in  the  middle  layers  (Kostenitsch,  Schirmer). 
The  cells  are  chiefly  mononuclear  lymphocytes,  but  polymorphonuclear 
leucocytes  and  extravasted  red  corpuscles  are  also  found.  Friedland 
found  giant-cells  both  in  the  sclerotic  nodules  and  in  the  choroid,  but 
it  is  doubtful  if  this  was  an  ordinary  case  of  scleritis  (v.  infra). 

Kostenitsch  found  the  scleral  cells  and  vessels  increased ;  the  lamellae 
normal,  but  separated  in  places  by  exudate.  The  infiltrating  cells 
between  the  lamellae  extended  forwards  into  the  cornea,  setting  up 
sclerosing  keratitis,  and  backwards  into  the  iris  and  ciliary  body  (see 
Fuchs'  Text-book,  fig.  64).  Schirmer  also  found  the  blood-vessels 
increased,  especially  in  the  outer  layers.  They  were  much  dilated  and 
surrounded  by  lymphocytes.  The  scleral  fibres  were  swollen  and 
redematous,  staining  deeply  with  haematoxylin. 


272  THE    PATHOLOGY    OF   THE    EYE 

In  the  more  severe  cases  the  laminae  of  the  sclerotic  are  pushed 
apart,  as  in  glaucomatous  eyes  (Birnbacher  and  Czermak),  and  indeed, 
glaucoma  is  not  infrequently  present.  In  other  cases  the  tension  is 
subnormal  (Steffens).  Schirmer  found  this  separation  of  the  bundles 
most  in  the  inner  layers,  which  were  also  peculiarly  plexiform.  Some 
were  granular,  and  the  nuclei  were  diminished  in  number. 

Later  many  fibres  and  cells  necrose,  or  undergo  fatty  or  hyaline 
degeneration.  They  are  then  slowly  absorbed,  without  ulceration. 
Rarely  the  lymphocytes  necrose,  their  nuclei  staining  more  faintly. 
The  elastic  fibres  also  break  up  and  are  gradually  absorbed. 
Accompanying  these  degenerative  changes  the  vessels  undergo 
sclerosis,  the  endothelium  proliferating. 

According  to  Schirmer,  proliferation  of  new  fibrous  tissue  may 
replace  atrophy.  He  found  an  equatorial  nodule  with  a  thick  mass  of 
young  granulation  tissue.  Baumgarten  found  great  thickening  of  the 
sclerotic  (4  mm.),  due  partly  to  increase  in  scleral  fibres,  partly  to 
infiltration  with  round-cells.  The  overgrowth  in  these  cases  may  be 
diffuse  or  circumscribed,  simulating  a  tumour  (fibroma  or  sarcoma). 
The  condition  has  been  called  hyperplastic  scleritis  (Schobl). 

Vossius,  in  a  case  of  typical  nodular  scleritis,  observed  greyish 
yellow  nodules  such  as  those  described  by  Fuchs.  They  were 
accompanied  by  lymphatic  cysts,  which  were  seen  clinically.  One  of 
the  larger  nodules  was  examined  microscopically.  The  subepithelial 
tissue  was  densely  infiltrated  with  leucocytes  ;  these  faded  off  internally 
into  the  main  mass,  which  was  chiefly  composed  of  endothelial 
(epithelioid)  cells  with  faintly  staining  nuclei.  There  was  no  infiltration 
below,  but  the  lymphatics  were  dilated  both  superficially  and  deeply. 
There  were  no  giant-cells  or  caseation,  and  inoculation  of  the  anterior 
chamber  of  rabbits  was  negative. 

The  sclerotic  nodules  show  a  predisposition  to  attack  the  neigh- 
bourhood of  the  anterior  perforating  ciliary  vessels,  and  extension  ot 
the  inflammation  is  usually  along  them.  In  many  cases  the  inflamma- 
tion is  equally  marked  in  the  sclerotic  and  in  the  uveal  tract.  In  these 
it  is  impossible  to  draw  any  deductions  as  to  priority  of  onset. 
Kostenitsch  and  Schirmer  regard  the  uveitis  as  primary.  The  latter 
thinks  that  there  is  always  a  combined  sclero-episcleritis  in  those  cases 
in  which  nodules  are  seen  clinically,  whilst  cases  with  violet  discoloura- 
tion of  the  sclera  and  little  prominence  may  be  due  to  a  pure  scleritis. 
In  one  of  Friedland's  cases  there  was  also  choroiditis,  but  the  patches 
did  not  correspond  with  those  of  the  scleritis.  This  may  be  explained 
by  transmission  along  the  vessels  and  lymph-channels,  but  is  regarded 
by  this  author  as  evidence  of  independent  foci  of  inflammation. 

Ulceration  as  a  result  of  ordinary  scleritis  must  be  regarded  as  of 
extreme  rarity,  yet  such  a  case  has  been  reported  by  Holthouse,  and 
examined  microscopically  by  Treacher  Collins.  It  occurred  in  a  woman 
set.  71  ;  there  was  no  history  of  tubercle  or  syphilis.  The  early  course 
was  that  of  typical  episcleritis,  but  later  ulceration  occurred  in  two 
places  over  one  nodule.  The  tension  became  —  i,  and  the  globe  later 
became  shrunken,  and  was  excised.  There  were  no  giant-cells,  nor 
were  tubercle  bacilli  found. 


THE    SCLEROTIC  273 

Allied  to  scleritis  are  the  cases  described  by  Coppez  and  Gayet.  In 
these  there  was  invasion  from  the  orbit  by  tumours  of  uncertain — 
possibly  lymphadenomatous — nature. 

Coppez  says  :  "  The  corneal  limbus  has  disappeared.  There  is  no 
definite  limit  between  sclera  and  cornea,  but  a  rosy  white  substance 
occurs  astride  the  two  membranes,  and  is  prolonged  under  the 
conjunctiva." 

Gayet  says  :  "  At  the  limbus  of  the  cornea  there  was  a  circle  of 
round  infiltrates  of  white  or  yellowish-white  colour,  more  or  less 
saturated,  nearly  touching  each  other,  and  forming  a  ring  round  a 
perfectly  clear  and  transparent  centre." 

SCHIRMER. — A.  f.  O.,  xli,  4,  1895.  UHTHOFF. — A.  f.  O.,  xxix,  3,  1883;  xlix,  3,  1900. 
WEDL  AND  BOCK. — Path.  Anat.  des  Auges,  Wien,  1886.  KOSTENITSCH. — A.  f.  A.,  xxviii, 

1894.        BlRNBACHER  AND  CZERMAK. A.  f.  O.,  XXxil,  2,    l886.        STEFFENS. K.  M.  f.  A.,  xli, 

1903.  BAUMGARTEX. — A.  f.  O.,  xxii,  2,  1876.  SCHOBL. — A.  f.  A.,  xx,  1889.  Vossius. — 
Ophth.  Klinik,  iv,  1900.  FRIEDLAND. — A.  f.  O.,  xlviii,  2,  1899.  HOLTHOUSE. — R.  L.  O.  H. 
Rep.,  xiii,  1893.  COPPEZ. — A.  d'O.,  xv,  1895.  GAYET. — A.  d'O.,  vi,  1886 ;  viii,  1888. 
EPISCLERITIS  PERIODICA  FUGAX  : — HUTCHIXSOX. — T.  O.  S.,  v,  1885.  NETTLESHIP. — 
T.  O.  S.,  viii,  1888.  FUCHS—  A.  f.  O.,  xli,  4.  1895. 


ANNULAR  SCLERITIS 

A  group  of  severe  cases  of  scleritis  has  been  isolated  by  German 
authors  under  the  term  brawny  infiltration  of  the  sclerotic  (Sulzige 
Infiltration  der  Sclera).  As  this  nomenclature  is  not  very  satisfactory 
I  have  suggested  the  term  annular  scleritis. 

Unlike  ordinary  scleritis,  which  usually  attacks  young  adults  affected 
with  tubercle  or  congenital  syphilis,  annular  scleritis  is  a  disease  of 
advanced  age.  All  the  cases  recorded  have  been  in  patients  over  sixty 
years  of  age,  and  most  of  them  were  women.  Both  eyes  are  usually 
affected,  though  often  to  a  very  unequal  extent.  The  progress  of  the 
disease  is  extremely  chronic,  with  periodic  exacerbations  and  remissions. 
The  prognosis  is  very  bad,  most  of  the  eyes  being  lost  ;  hence  the 
large  number  which  have  been  examined  microscopically  as  compared 
with  ordinary  scleritis,  pathological  reports  of  which  are  extremely 
rare. 

The  locality  and  extent  of  the  infiltration  is  characteristic.  Even 
when  typical  scleritis  invades  the  whole  circumcorneal  area  it  leaves  the 
limbus  itself  free,  thus  differing  from  phlyctenular  nodules.  Here,  on 
the  other  hand,  the  corneal  margin  is  the  essential  site  of  the  affection, 
and  from  this  spot  the  infiltration  spreads  on  both  sides  into  the 
neighbouring  tissues,  having  a  sharp  edge  on  the  side  of  the  cornea, 
which  it  partly  overlaps,  and  gradually  passing  into  normal  tissue  on 
the  side  of  the  sclerotic.  In  advanced  cases  extension  continues  in 
each  direction,  so  that  it  reaches  the  equator  posteriorly,  but  never 
much  exceeds  this  level,  whilst  anteriorly  it  invades  the  cornea  as  a 
peripheral  sclerosing  keratitis,  ever  advancing  slowly  towards  the 
centre. 

18 


274 


THE    PATHOLOGY    OF   THE    EYE 


The  appearances  of  the  infiltration  were  sufficiently  characteristic 
to  lead  Schlodtmann  to  identify  the  complaint  by  them.  In  other 
cases  the  existence  of  the  scleritis  has  only  been  discovered  subsequently 
to  the  removal  of  the  eye.  In  typical  cases  the  swelling  is  gelatinous 
and  succulent,  and  has  a  brownish-red  colour. 

Besides  the  cornea,  the  uveal  tract  is  usually  inflamed,  especially 
the  anterior  part  of  the  choroid  and  the  ciliary  body.  As  in  the  case  of 
ordinary  scleritis,  discussion  has  arisen  as  to  whether  this  uveitis  is 
secondary  to  the  scleritis  or  causal.  In  each  case  it  is  probably  a 
secondary  phenomenon,  sometimes  a  true  sequel,  at  others  a  mere 
concomitant. 

There  are  three  records  of  microscopical  examination  of  annular 
scleritis.  Schlodtmann  describes  three  cases  clinically,  one  of  them 


FIG.  182. — ANNULAR  SCLERITIS.      x  3. 
Holmes  Spicer  and  Parsons,  T.  O.  S.,  xxii. 

pathologically.  The  patient  was  aged  seventy-four.  The  conjunctiva  was 
reddened  for  about  5  mm.  around  the  cornea,  traversed  by  large  vessels, 
and  raised  by  a  brawny,  reddish-brown  thickening  above  the  under- 
lying tissue.  In  this  area  there  was  enormous  dilatation  of  blood- 
vessels and  lymphatics,  the  latter  forming  cavernous  spaces  under  the 
epithelium.  In  the  deeper  layers  was  an  intense  leucocytic  infiltration, 
containing  numerous  necrotic  masses,  communicating  with  each  other 
in  a  plexiform  manner.  Giant-cells  were  present  to  an  enormous 
number.  No  tubercle  bacilli  could  be  found. 

In  Friedland's  case  the  distribution  was  the  same ;  there  was  no 
tendency  to  suppuration,  and  Friedland  points  out  that  the  leucocytes 
were  all  mononuclear  cells  with  a  relatively  large  necleus  and  little 


THE    SCLEROTIC 


275 


protoplasm.  Distinct  degenerative  processes  (breaking  up  of  nuclei, 
amorphous  material,  etc.)  were  present  both  in  the  scleral  fibres  and 
also  amongst  the  round-cells.  The  absence  of  giant-cells,  epithelioid 
cells  and  bacilli  was  considered  sufficient  to  exclude  tubercle.  There 
was  no  evidence,  clinical  or  pathological,  of  syphilis,  gout,  or  rheuma- 
tism. In  one  eye  choroiditis  came  on  late  and  led  to  failure  of  sight; 
in  the  other  no  uveitis  occurred.  Friedland  regards  the  scleritis  and 
choroiditis  as  "primary  independent  diseases  arising  from  a  common 
cause." 

Uhthoffs  case  was  similar  in  localisation,  extent,  and  general 
histological  conditions.  There  were  no  giant-cells,  the  round-cells 
were  all  mononuclear,  showing  marked  nuclear  degeneration,  and  the 


FIG.  183. — ANNULAR  SCLERITIS.      x  55. 

From  just  behind  the  ora  serrata.  Note  the  dense  infiltration  of  the  sclerotic, 
the  laminae  of  which  are  separated  by  round-cells.  The  choroid  and  retina  are 
much  degenerated. 


lymphatics  and  blood-vessels  were  dilated.  The  author  draws  attention 
to  the  thickening  of  the  walls  of  the  blood-vessels,  with  endothelial 
proliferation,  leading  to  partial  and  even  complete  blocking  of  the 
lumina ;  and  regards  the  obstruction  to  circulation  as  an  important 
factor  in  the  disease.  There  were  distinct  nodules  in  places,  recalling 
trachoma  follicles,  composed  of  a  central  mass  of  endothelial  cells 
surrounded  by  a  zone  of  infiltration.  No  micro-organisms  could  be 
found. 

The  case  which  I  have  examined  was  a  woman,  ast.  68,  whose  left 
eye  had  been  injured  two  years  previously  by  a  blow.     Both  eyes  were 


276  THE    PATHOLOGY    OF   THE    EYE 

inflamed  ;  the  vision  of  the  right  was  f .  The  left  had  annular  scleritis, 
keratitis  punctata,  iritis,  opacities  in  the  lens,  arterio-sclerosis,  cystic 
retina  at  posterior  pole,  and  increased  tension  with  cupped  disc  (Fig.  182). 
The  scleritis  was  found  to  extend  entirely  round  the  anterior  part  of  the 
globe,  and  back  to  the  equator.  It  is  deepest  above,  where  the  sclerotic 
is  reduced  to  extreme  thinness,  only  about  half  a  dozen  lamellae  remain- 
ing intact.  The  superficial  lamellae  are  separated  from  each  other  and 
partly  destroyed  by  dense  infiltration  with  mononuclear  lymphocytes 
(Fig.  183).  The  blood-vessels  have  proliferated,  and  are  dilated  and 
full  of  blood-corpuscles.  Some  polymorphonuclear  leucocytes  are  found 
near  the  blood-vessels,  especially  in  the  episcleral  tissue.  In  places 
there  are  signs  of  endothelial  proliferation  in  the  vessels,  but  this  is  not 
marked.  The  infiltration  is  diffuse,  and  there  are  no  nodules,  nor  are 
there  any  giant-cells. 

In  this  case  the  inflammatory  and  degenerative  changes  are  so  wide- 
spread that  it  is  impossible  to  be  sure  of  their  relative  sequence.  Uveitis 
is  considered  to  be  the  precursor  of  ordinary  scleritis  by  Arlt, 
Kostenitsch,  Schirmer,  Greeff,  and  others.  The  direction  of  the 
lymph-stream,  and  the  facility  of  transmission  along  the  course  of  the 
anterior  ciliary  vessels  are  in  favour  of  this  view.  The  essential  identity 
of  the  processes  in  episcleritis  and  scleritis,  the  invariable  absence  of 
uveitis  in  pure  episcleritis  and  its  almost  constant  presence  in  severe 
cases  of  scleritis,  however,  point  to  uveitis  as  a  sequel  rather  than  as  a 
causal  agent.  Moreover,  it  is  probable  that  scleritis  often  occurs  with- 
out being  diagnosed,  and  in  the  absence  of  any  evidence  of  uveitis. 
Friedland,  too,  in  a  case  of  typical  scleritis,  found  that  the  patches  of 
choroiditis  did  not  correspond  in  position  with  the  nodules  of  scleritis. 

The  extreme  chronicity  of  all  forms  of  the  disease  points  to  a 
specific  inflammatory  process,  a  view  which  is  borne  out  by  the  nature 
of  the  leucocytes  present.  The  advance  is  doubtless  impeded  by  the 
extreme  resistance  of  scleral  tissue  to  invasions  of  all  kinds,  inflam- 
matory or  neoplastic ;  and  perhaps  also  by  its  direction  contrary  to 
the  normal  lymph-flow. 

The  line  of  exit  of  the  venae  vorticosae  seems  to  limit  the  backward 
progress  of  the  inflammation ;  and  this  is  possibly  due  to  better  nutrition 
of  the  sclerotic  behind  the  equator. 

Schlodtmann's  case,  although  the  one  which  was  first  described  of 
this  kind  of  scleritis,  is  open  to  another  interpretation.  It  may  well 
be  a  severe  case  of  the  granulomatous  type  of  infiltration.  To  this 
class  probably  belong  the  cases  recorded  by  Brailey,  Donald  Gunn, 
and  others  (v.  p.  278). 

The  presence  of  large  numbers  of  giant-cells  in  Schlodtmann's  case 
points  to  its  being  of  different  origin  to  the  other  cases.  In  the  absence 
of  definite  tubercles  with  caseation,  and  considering  the  inability  to 
find  tubercle  bacilli,  the  giant-cells  may  have  been  ordinary  foreign- 
body  giant-cells  (Fremdkorper-Riesenzellen)  such  as  are  found  in 
granulation  tissue.  However  this  may  be,  there  can  be  little  doubt 
that  the  severer  cases  of  deep  scleritis  show  definite  characteristics  as 
regards  localisation,  nature  of  infiltration,  etc.,  which  justify  their 
being  classed  apart. 


THE    SCLEROTIC  277 

*  PARSONS. — Ophth.  Rev.,  1902:  see  aho  SPICER,  T.  O.  S.,  xxii,  1902.  SCHLODTMANN. 
— A.  f.  O.,  xliii,  i,  1897.  FRIEDLAXD. — A.  f.  O.,  xlviii,  2,  1899.  UHTHOFF. — A.  f.  O.,  xlix, 
3,  1900. 

PURULENT  SCLERITIS 

Ulceration  and  suppuration  of  the  sclerotic  are  of  extreme  rarity. 
The  sclera  possesses  great  resistance  against  invasion  both  by  acute 
inflammatory  processes  and  by  new  growths.  In  purulent  panophthal- 
mitis  the  inner  surface  of  the  sclera  is  usually  smooth  and  unaffected ; 
it  is  only  in  very  late  stages  that  it  becomes  eroded,  and  may  be 
perforated.  In  these  cases  the  perforation  is  generally  in  front  of  the 
equator ;  the  inflammation  travels  along  the  course  of  the  anterior 
ciliary  vessels,  and  perforation  takes  place  at  the  corneo-scleral  margin. 
Arlt  pointed  out  that  it  is  the  sclera  and  not  the  cornea  which  is  thus 
perforated.  He  also  first  described  a  case  of  purulent  scleritis. 

In  Schlodtmann's  first  case  the  intense  leucocytic  infiltration  with 
marked  necrosis  is  suggestive  of  actual  suppuration,  but  there  is  no 
definite  information  as  to  the  nature  of  the  leucocytes  nor  of  definite 
suppuration. 

It  is  doubtful  whether  abscess,  in  the  ordinary  sense  of  the  word, 
ever  occurs  in  the  sclera.  Suppuration  is  almost  invariably  the  result 
of  purulent  choroiditis,  resulting  from  an  intra-ocular  foreign  body,  and 
panophthalmitis  from  other  causes.  Groups  of  leucocytes  are  often 
found  in  the  later  stages  in  the  inner  layers  of  the  sclera,  and  these 
may  burst  into  the  vitreous,  producing  ulcerated  patches.  They  lead 
to  over-production  of  fibrous  tissue,  which  pierces  the  choroid  and 
retina,  and  forms  a  knob-like  mass  in  the  vitreous.  In  severer  cases  the 
globe  is  ruptured,  and  Alt  regards  the  equator  as  the  usual  site,  at  the 
exit  of  the  vense  vorticosae.  The  consensus  of  opinion  is,  however,  in 
favour  of  the  weak  spot  of  the  eye,  viz.  the  corneo-scleral  margin,  and 
the  cases  in  which  the  rupture  takes  place  at  the  equator  are  excep- 
tional, and  are  probably  due  to  previous  blocking  of  the  angle  of  the 
anterior  chamber,  which  becomes  stronger  by  the  deposition  of  new 
fibrous  tissue. 

As  in  a  case  described  by  Alt,  the  process  may  be  extremely  rapid, 
so  that  the  swollen  sclera  resembles  a  staphyloma.  In  this  case  the 
sclera  was  six  times  its  normal  thickness,  and,  together  with  the  epi- 
scleral  tissue,  was  intensely  infiltrated  with  leucocytes. 

Alt  regards  implication  of  the  ciliary  nerves  as  a  factor  in  the  pro- 
duction of  sympathetic  ophthalmia. 

Ulceration  from  outside  is  even  rarer  than  from  within,  von 
Graefe  describes  a  case  after  a  strabismus  operation ;  and  suppurating 
sutures,  with  ulceration  of  the  neighbouring  sclera,  must  have  been 
seen  by  many  surgeons,  though  they  have  not  been  recorded. 

Abscesses  on  the  surface  of  the  sclerotic  have  been  described  by 
Boyd  in  glanders. 

ARLT. — Die  Krankheiten  des  Auges,  ii,  p.  n.  ALT. — Lectures  on  the  Human  Eye, 
p.  44,  New  York,  1880.  v.  GRAEFE. — A.  f.  O.,  iii,  2,  1857.  BOYD. — Tr.  Path.  Soc.,  xxxiii. 


278  THE    PATHOLOGY   OF   THE    EYE 


SYPHILIS 

Gummata  of  the  ciliary  body,  etc.,  may  often  lead  to  destruction  of 
the  sclerotic.  They  then  appear  clinically  as  gummata  of  the  sclerotic, 
and  have  often  been  described  as  such.  In  many  of  the  cases,  indeed, 
it  is  impossible  to  be  certain  where  the  disease  actually  commenced, 
and  when  we  remember  the  frequency  of  gummatous  deposits  in  the 
connective  tissues,  it  would  be  strange  if  they  did  not  occasionally 
occur  in  the  sclerotic. 

Alexander  found  eight  cases  of  gumma,  limited  to  the  sclerotic,  in 
the  literature.  An  earlier  case  recorded  by  Bull  is  not  included.  In 
Hirschberg's  case,  a  girl  of  fifteen,  there  was  a  swelling  from  the  limbus 
to  the  equator.  Rothmund  and  Eversbusch  recorded  two  cases,  and 
two  were  also  recorded  by  Higgens.  In  one  of  the  latter  there  were 
three  nodules.  Others  have  been  described  by  Andrews,  Minor,  Alt, 
and  others,  and  Donald  Gunn's  cases  probably  belong  to  the  same 
category. 

The  disease  has  never  been  examined  microscopically,  except  in 
cases  in  which  there  has  been  extensive  affection  of  other  parts.  The 
histological  characters  are  then  similar  to  those  found  in  the  cases  of 
gumma  of  the  ciliary  body  which  I  have  described  (v.  infra). 

Gummatous  disease  of  the  episclera  occurs,  and  may  be  difficult  to 
differentiate  from  other  conditions  of  the  episclera  and  conjunctiva. 
An  interesting  case,  in  which  there  were  giant-cells,  has  been  described 
by  Peppmiiller,  but  tubercle  bacilli  were  finally  found  after  prolonged 
search.  I  have  seen  an  exactly  similar  case,  and  in  both  the  disease 
rapidly  cleared  up  under  antisyphilitic  treatment  (v.  p.  78). 

ALEXANDER. — Syphilis  und  Auge,  Wiesbaden,  1889.  BULL. — Tr.  Amer.  O.  S.,  1874. 
HIRSCHBERG. — In  Nagel's  Jahresb.,  1877.  ROTHMUND  AND  EVERSBUSCH. — Mittheilungen 
aus  der  k.  Universitatsklinik  zu  Miinchen,  1882.  HIGGENS. — Brit.  Med.  Jl.,  1882. 
ANDREWS. — A.  of  O.,  xi,  1882.  MINOR. — A.  of  O.,  xiv,  1885.  ALT. — Amer.  Jl.  of  Ophth., 
1893.  DONALD  GUNN. — T.  O.  S.,  xiv,  1894.  PEPPMULLER. — A.  f.  O.,  xlix  and  1,  1900. 

TUBERCLE 

It  is  doubtful  whether  primary  tubercle  of  the  sclerotic  exists.  It 
is  frequently  invaded  secondarily  to  the  uveal  tract. 

Kohler  reports  a  case  in  which  the  choroid  and  Tenon's  capsule 
were  but  slightly  affected  with  miliary  tubercles,  whilst  the  sclerotic 
was  the  seat  of  a  caseous  mass,  projecting  4  mm.,  at  a  spot  3  mm.  out- 
side the  optic  nerve.  Around  the  necrotic,  diffusely  staining  material 
were  giant-cell  systems  with  epithelioid  cells.  There  were  miliary 
tubercles  in  the  sclerotic  in  the  neighbourhood. 

Brailey's  case  of  scleritis  was  probably  tubercular;  it  occurred  in 
the  left  eye  of  a  scrofulous  child  of  nine  and  a  half  with  enlarged  cervical 
glands.  The  episcleral  tissue  was  thickened  and  greyish  in  colour,  the 
surface  breaking  down  and  ulcerating  in  several  places  after  a  few  weeks' 
duration  of  the  disease.  Portions  removed  for  diagnosis  showed 
tubercular  nodules  with  lymphoid  infiltration,  giant-cells,  and  definite 
caseation.  Tubercle  bacilli  could  not  be  demonstrated. 


THE    SCLEROTIC  279 

Miiller  also  described  a  cyst  in  the  sclerotic,  the  walls  of  which  were 
composed  of  miliary  tubercles. 

Schlodtmann's  case  (v.  p.  276)  may  perhaps  also  have  been  tubercular 
or  syphilitic,  and  a  case  of  cyclo-scleritis  described  by  Utermohlen  was 
almost  certainly  tubercular. 

The  sclerotic  is  often  much  thickened  by  fibrous  deposits  over  uveal 
tubercles  (Liebrecht).  Perforation,  with  the  formation  of  a  tubercular 
ulcer,  occurs  most  commonly  at  the  site  of  the  anterior  perforating 
ciliary  vessels. 

KOHLER. — Dissertation,  Wiirzburg.  1884.  BRAILEY. — T.  O.  S.,  ix,  1889.  MULLER. — 
Wiener  med.  Presse,  1890.  UTERMOHLEN. — Diss.,  Amsterdam,  1902 ;  see  STEFFENS, 
K.  M.  f.  A.,  xli,  1903.  LIEBRECHT. — A.  f.  O.,  xxxvi,  4,  1890. 


LEPROSY 

Episcleral  nodules  occur  in  leprosy,  and  have  the  usual  character- 
istics (v.  p.  7).  In  the  sclerotic  the  conditions  of  extension  are  impeded 
by  the  denseness  of  the  tissue,  but  slow  invasion  takes  place  along  the 
perivascular  and  interlamellar  lymph-spaces.  The  lamellae,  including 
the  elastic  fibres,  are  destroyed.  The  lepra  bacilli  often  form  spindle- 
shaped  masses  and  long  rows,  around  which  there  are  only  few  round- 
cells.  This  arrangement  resembles  that  found  in  the  cornea,  but  is 
less  regular.  Lie  was  unable  to  find  bacilli  in  the  posterior  part  of  the 
sclerotic. 

(For  BIBLIOGRAPHY,  see  "Lids,"  "  Cornea.") 


DEGENERATIONS 

Hyaline  degeneration  of  the  scleral  laminae  is  found  under  pingue- 
cula,  and  in  other  degenerative  conditions. 

Fatty  degeneration  occurs  in  old  age,  and  in  inflammatory  con- 
ditions. 

Calcification  also  occurs  sometimes  after  old  inflammatory  pro- 
cesses, and  in  old  age.  After  removal  of  the  lime-salts  the  scleral 
lamellae  show  an  apparently  normal  histological  structure.  In  rare 
cases  actual  bone  formation  may  take  place. 


CYSTS 

Several  cases  of  cyst  of  the  sclerotic  have  been  reported,  but  few  have 
been  examined  microscopically.  Some  cystic  cicatrices,  implantation 
cysts,  etc.,  might  easily  be  mistaken  for  them.  Mackenzie  and  Hasner 
recorded  cases  clinically. 

Colbourn  described  a  corneo-scleral  cyst  containing  clear  fluid  in  a 
boy  aet.  15  ;  both  the  inner  and  outer  walls  consisted  of  corneo-scleral 


280  THE    PATHOLOGY    OF   THE    EYE 

tissues.  The  author  could  find  only  two  similar  cases  in  the  literature, 
one  due  to  a  fragment  of  steel,  the  other  to  a  cysticercus. 

Rogman  saw  a  cyst  near  the  cornea  in  a  child  of  thirteen.  It  was 
trilobate,  and  contained  clear  fluid.  Microscopic  examination  of  the 
outer  wall  showed  that  it  consisted  of  fibrous  tissue  covered  with  con- 
junctival  epithelium.  There  was  no  epithelium  or  endothelium  on  the 
inner  surface. 

Lagrange  described  a  scleral  cyst  following  a  strabismus  operation. 
There  was  no  histological  examination. 

Congenital  cysts  are  not  truly  cysts  of  the  sclerotic,  but  are  due  to 
defects  of  development  in  that  and  the  other  membranes. 

MACKENZIE. — Diseases  of  the  Eye,  ii,  London,  1854.  HASNER. — Klin.  Vortrage  iiber 
Augenheilkunde,  Prag,  1860.  COLBURN. — Jl.  of  the  Amer.  Ass.,  1896.  ROGMAN. — Ann. 
d'Oc.,  cxvii,  1897.  LAGRANGE. — Tumeurs  de  I'GEil,  i,  Paris,  1901. 


TUMOURS 
BENIGN  TUMOURS 

Hyperplasia,  though  not  actually  a  tumour  formation,  may  be  con- 
veniently mentioned  here.  The  sclerotic  often  looks  enormously 
thickened  in  shrunken  globes.  Thickening  is  here  more  apparent  than 
real,  and  is  due  to  contraction  of  the  elastic  tissues  and  folding  ;  there 
is,  however,  often  evidence  of  inflammatory  hyperplasia.  Wounds  and 
localised  inflammatory  processes  usually  lead  to  thinning,  owing  to  the 
action  of  the  normal  or  increased  intra-ocular  tension.  They  occasionally 
cause  localised  thickening.  The  histological  process  and  results  are 
identical  with  the  healing  of  scleral  wounds  (v.  p.  267),  except  that  the 
development  of  cicatricial  tissue  is  excessive. 

Enormous  deposits  of  scar  tissue  may  be  found  around  foreign 
bodies  embedded  in  the  sclerotic. 

Thickening  may  be  due  to  enormous  infiltration  with  round-cells 
(Schobl).  Gayet  described  the  simultaneous  occurrence  of  this  condition 
in  both  eyes,  and  attributed  it  to  a  bacterial  origin. 

Fibroma  of  the  sclerotic  has  been  described  in  a  unique  case  by 
Saemisch.  It  was  situated  near  the  posterior  part  on  the  inner  side ; 
there  were  many  signs  of  inflammation  in  other  parts  of  the  eye.  Most 
probably  the  case  was  one  of  inflammatory  hyperplasia. 

Fibro-chondroma  near  the  limbus  in  a  child  of  nine  months  has 
been  reported  by  Castaldo.  It  was  probably  a  teratoid  epibulbar 
growth.  Cartilage  has  often  been  found  in  the  sclerotic  in  congenital 
malformations.  It  may  be  a  reversion  to  the  avian  type. 

Osteoma,  described  by  Blasius,  and  by  Watson,  have  probably  the 
same  explanation,  though  in  the  latter  case  it  was  situated  between  the 
superior  and  internal  recti,  a  rather  unusual  situation  for  congenital 
growths.  Moreover,  the  occurrence  of  bone  in  the  sclerotic  of  lower 
animals  normally,  and  its  rare  occurrence  in  man  following  inflammatory 
and  senile  changes  must  be  borne  in  mind. 


THE    SCLEROTIC  281 

Telangiectasis  in  the  sclerotic  has  been  described  by  Quaglino.  The 
growths  were  multiple  and  were  probably  episcleral. 

SCHOBL. — A.  f.  A.,  xx,  1889.  GAYET. — A.  d'O.,  viii,  1888.  SAEMISCH. — A.  f.  A.,  ii, 
1872.  CASTALDO. — Riv.  di  Ott.,  1893.  BLASIUS. — In  MACKENZIE,  Diseases  of  the  Eye,  ii, 
1854.  WATSON. — Tr.  Path.  Soc.,  xxii.  QUAGLINO. — Ann.  di  Ott.,  ii,  1872. 

MALIGNANT  TUMOURS 

Eliminating  conjunctival  and  episcleral  sarcoma,  there  is  no 
indubitable  case  of  primary  sarcoma  of  the  sclerotic.  As  Lagrange 
points  out,  the  question  is  allied  to  the  very  doubtful  occurrence  of 
sarcoma  in  tendons.  The  earlier  cases  described  by  Hirschberg, 
Neumann,  Gorecki,  etc.,  are  open  to  doubt,  and  would  probably  be 
classified  otherwise  now.  The  most  likely  case  is  a  melanotic  sarcoma 
reported  by  Achenbach.  It  occurred  around  a  posterior  ciliary  nerve, 
the  optic  nerve  and  choroid  being  normal.  The  author  considered  that 
it  arose  from  the  pigmented  perineural  tissue. 

Secondary  sarcoma  of  the  sclerotic  is  of  course  common  when  that 
disease  attacks  the  uveal  tract.  It  arises  almost  exclusively  by 
propagation  along  the  perivascular  and  perineural  lymph-spaces,  though 
malignant  thrombi  may  occur  in  the  vessels. 

Secondary  carcinoma  of  the  sclerotic  arises  from  metastatic  carci- 
noma of  the  choroid  in  exactly  the  same  manner. 

Secondary  epithelioma  of  the  sclerotic  arises  by  continuity  from 
epithelioma  of  the  limbus. 

Secondary  glioma  of  the  sclerotic  arises  from  glioma  of  the  retina 
by  continuity  with  secondary  extensions  in  the  choroid  along  the 
perforating  vessels,  and  also  by  invasion  of  the  interlamellar  spaces. 
The  lamellae  are  very  resistant,  and  remnants  persist  almost 
indefinitely. 

HIRSCHBERG. — K.  M.  f.  A.,  vi,  1868.     ACHENBACH. — Virchow's  Archiv,  cxliii,  1896. 


CHAPTER    V 
THE    IRIS   AND    ANTERIOR    CHAMBER 

THE    NORMAL    IRIS    AND    ANTERIOR    CHAMBER 

THE  ciliary  body  may  be  considered  roughly  to  be  shaped  like  an 
isosceles  triangle  with  the  apex  directed  backwards  (Fig.  184).  The 
iris  does  not  spring  from  the  outer  angle  of  the  base,  but  from  near  the 
middle  ;  consequently  part  of  the  anterior  surface  of  the  ciliary  body 
enters  into  the  formation  of  the  anterior  chamber. 

In  lower  mammals  and  in  the  human  fetus  the  angle  of  the  anterior 
chamber  is  occupied  by  a  meshwork  of  fibres,  stretching  from  the  back 
of  the  anterior  part  of  the  sclerotic  to  the  ciliary  body  and  the  root  of 
the  iris.  Indeed,  it  pushes  its  way  backwards  for  a  short  distance 
between  the  ciliary  muscle  and  the  ciliary  processes.  Looked  at  from 
within,  this  network  resembles  the  teeth  of  a  comb,  and  was  hence 
called  the  ligamentum  pectinatum  iridis  (Hueck).  The  maze  of  meshes 
between  the  trabeculae  were  investigated  by  Fontana,  and  are  called  the 
spaces  of  Fontana.  The  fully  developed  ligamentum  pectinatum  consists 
of  two  parts  :  an  outer  more  compact  part,  lying  in  apposition  with  the 
sclerotic,  and  forming  the  inner  wall  of  the  great  venous  plexus,  the 
canal  of  Schlemm ;  and  an  inner  looser  part.  The  latter  persists  in  man 
until  the  sixth  foetal  month  (Rochon-Duvigneaud,  Treacher  Collins), 
after  which  it  disappears,  and  with  it  disappear  most  of  the  spaces  of 
Fontana,  which  can  scarcely  be  said  to  exist  in  the  adult.  The  fetal 
condition  is  often  retained  in  microphthalmic  eyes  (Fig.  185). 
Rochon-Duvigneaud  called  the  outer  persistent  portion  the  sclero- 
corneal  trabecular  system,  and  looked  upon  it  as  derived  by  dissociation 
from  the  inner  circular  lamellae  of  the  sclerotic. 

The  ligamentum  pectinatum  iridis  consists  of  trabeculae  of  fibrous 
tissue,  made  up  of  bundles  of  fine  fibrillae.  The  finer  details  of 
the  arrangement  of  the  trabeculae  have  recently  been  investigated  by 
Asayama.  Descemet's  membrane  splits  up  at  the  periphery  into  fibres, 
which  pass  into  the  trabeculae ;  but  these  do  not  take  on  Weigert's 
elastic-tissue  stain  deeply.  The  trabeculse  are  covered  by  endothelial 
cells  with  large  oval  or  round  nuclei ;  these  are  continuous  with  those 
of  Descemet's  membrane  and  with  those  covering  the  iris. 

The  canal  of  Schlemm  is  really  a  venous  plexus  surrounding  the 


THE    IRIS    AND    ANTERIOR   CHAMBER 


283 


angle  of  the  chamber,  and  lying  in  the  inner  part  of  the  extreme 
anterior  part  of  the  sclerotic.  In  meridional  section  it  is  usually  oval, 
but  is  often  irregular,  or  cut  twice  in  the  same  section,  showing  that 
it  is  convoluted  and  also  plexiform.  It  is  lined  by  endothelium 
lying  on  a  fine  fibrous  basis,  which  separates  it  from  the  endothelium  of 
the  spaces  of  Fontana.  There  is  therefore  a  thin  membrane  between 
the  canal  of  Schlemm  and  the  anterior  chamber,  a  fact  which  has  also 
been  demonstrated  by  filtration  experiments.  The  trabeculse  often 
have  pigment-cells,  especially  in  old  people,  usually  most  in  the 
posterior  part. 

The  iris  is  made  up  principally  of  vessels,  nerves,  and  unstriped 
muscle,  bound  together  by  a  very  loose  cellular  stroma.  This  consists 
of  a  small  amount  of  fine  fibrous  tissue,  with  branching  spindle-  and 
star-shaped  cells,  with  long  interlocking  processes:  most,  of  them 
contain  brown  pigment  granules,  varying  in  amount  according  to  the 


FIG.  184. — THE  NORMAL  CILIARY  REGION. 

From  Lawson,  after  Fuchs.  S,  sclerotic;  C,  cornea;  L,  lens;  R,  retina; 
Ch,  choroid  ;  I,  iris;  P,  ciliary  processes;  M,  longitudinal  fibres  of  ciliary  muscle; 
Mu,  circular  fibres  of  ciliary  muscle;  1,  ligamentum  pectinatum  ;  s,  canal  of 
Schlemm;  a,  circulus  iridis  major;  sp,  sphincter  piipillse;  v,  retinal  pigment 
epithelium,  turning  forwards  at  pupil,  p  ;  ci,  anterior  ciliary  vessels  ;  O,  pars  plana 
of  ciliary  body ;  o,  ora  serrata  ;  z  z',  zonule  of  Zinn  ;  i,  canal  of  Petit ;  pe,  pc,  layers 
of  pars  ciliaris  retinae. 

colour  of  the  iris,  and  absent  in  albinos.  The  vessels  run  radially 
with  the  exception  of  the  circulus  arteriosus  iridis  minor,  which  is 
situated  a  short  distance  from  the  pupillary  edge.  The  major  arterial 
circle  lies  in  the  ciliary  body,  at  the  root  of  the  iris,  in  man.  The 
vessels  have  a  thin  muscular  coat  and  a  very  thick  adventitia. 

The  posterior  part  of  the  stroma  near  the  pupillary  edge  is  occupied 
by  a  ring  of  unstriped  muscle,  the  sphincter  iridis.  This  is  inserted  by 
oblique  off-shoots  into  the  posterior  wall,  so  that  the  posterior  pigment 
layer  is  often  seen  to  be  drawn  into  a  fold  (Grunert). 

The  anterior  surface  is  irregular,  and  is  covered  by  endothelium, 
continuous  with  that  of  the  ligamentum  pectinatum.  There  are  breaks 
in  the  continuity  of  the  endothelium  leading  down  into  irregular  spaces 


284  THE    PATHOLOGY    OF   THE    EYE 

or  crypts  in  the  stroma,  which  thus  communicates  directly  with  the  an- 
terior chamber.  The  largest  are  situated  over  the  circulus  minor. 
They  are  not  lined  with  endothelium,  but  fibres  covered  with  endo- 
thelium  often  span  the  mouths.  Fuchs,  who  has  paid  particular 
attention  to  them,  only  found  them  once  quite  covered  in  by  a  fine 
membrane. 

The  stroma  is  denser  immediately  below  the  anterior  endothelium 
(anterior  limiting  layer),  and  very  cellular,  with  little  or  no  fibrous  tissue. 
The  cells  here  are  often  deeply  pigmented,  and  Baas  found  groups  of 
round  pigrnent-cells  between  the  endothelium  and  the  stroma.  Con- 
genital pigmented  spots  ("  naevi  ")  are  not  uncommon  here  (v.  infra.). 

The  posterior  limiting  layer  of  the  stroma  consists  of  a  fine  fibrillary 


FIG.  185. — FCETAL  CONDITION  OF  THE  ANGLE,      x    18. 

Parsons,  T.  O.  S.,  xxii.  From  a  case  of  microphthalmos.  The  angle  is  filled 
with  spongy  tissue,  containing  well-marked  spaces  of  Fontana ;  this  extends  well  in 
front  of  Schlemm's  canal.  Other  features  showing  arrest  of  development  are  seen 
in  the  persistence  of  the  posterior  vascular  sheath  of  the  lens  and  the  condition  of 
the  pars  ciliaris  retinae. 

membrane  (Bruch's  membrane),  probably  representing  the  lamina  vitrea 
of  the  choroid,  but  much  less  conspicuous.  In  many  animals,  e.g.  the 
albino  rabbit,  radial  unstriped  muscle-fibres,  are  found  in  and  upon 
this  membrane  (dilatator  iridis).  These  are  difficult  to  demonstrate  in 
man,  but  must  be  admitted  both  on  anatomical  and  physiological 
grounds. 

Juler  demonstrated  fusiform  cells,  with  rod-shaped  nuclei,  indis- 
tinguishable from  unstriped  muscle-fibres,  in  a  continuous  layer 
anterior  to  the  pigment  epithelium,  which  had  been  bleached  with 
euchlorine.  Grunert,  in  bleached  flat  preparations,  found  rod-shaped 
nuclei  here,  which  stained  yellow,  like  the  sphincter  fibres,  with 


THE    IRIS    AND    ANTERIOR   CHAMBER  285 

van  Gieson.  In  the  contracted  pupil  they  lay  in  the  limiting  layer;  in 
the  dilated  pupil  they  projected  backwards.  It  is  not  certain  that 
these  cells  were  not  the  spindle-shaped  retinal  epithelial  layer,  and 
indeed,  Grunert  admits  his  nuclei  into  this  layer.  It  would  seem  a 
priori  improbable  that  epiblastic  cells  should  develop  into  muscle-fibres, 
but  the  phenomenon  would  not  be  unique,  since  the  arectores  pilorum 
of  the  skin  are  of  epiblastic  origin.  A  very  elaborate  investigation  of 
the  subject  has  been  carried  out  by  Szili,  Jr.,  working  under  van 
Lenhossek.  He  concludes  that  both  the  sphincter  and  the  dilatator  are 
developed  from  the  retinal  epiblast.  The  former  arises  at  the  com- 
mencement of  the  fourth  month  from  the  epithelial  cells  at  the  junction 
of  the  two  layers  of  the  secondary  optic  vesicle.  The  latter  is  formed 
by  the  transformation  of  the  anterior  layer  of  epithelium  in  the  seventh 
month.  Bruch's  membrane  forms  a  continuous  layer  of  fine  fibres, 
and  is  of  unequal  thickness  up  to  7 — 8  n ;  it  has  no  nuclei.  It  stains 
yellow  with  van  Gieson,  like  muscle-tissue.  Between  it  and  the  pos- 
terior epithelium  is  the  dilatator,  consisting  of  low,  flat  cells,  with 
horizontal  oval  nuclei.  In  places  between  these  and  the  posterior 
epithelium  there  are  groups  of  cells  with  round  nuclei ;  these  are  epi- 
thelial cells  of  the  anterior  layer  which  have  not  been  transformed  into 
muscle. 

The  dilatator  iridis  can  be  easily  demonstrated  by  bleaching  with 
permanganate  of  potassium  and  oxalic  acid.  It  stains  well  by  Mallory's 
neuroglia  stain  (Verhoeff,  Parsons). 

The  posterior  surface  of  the  iris  is  covered  by  a  double  layer  of 
retinal  epithelium  (pars  retinalis  iridis,  pars  iridica  retinae).  This  is 
deeply  pigmented  except  in  albinos,  and  the  shape  of  the  cells  can  only 
be  made  out  in  bleached  sections.  The  pigment  granules  are  dark 
brown,  mostly  round,  but  some  are  rod-shaped,  like  the  retinal  pigment 
in  lower  mammals.  The  cells  are  cubical  or  polygonal,  and  large  in 
the  posterior  and  superficial  layer,  and  flat  and  spindle-shaped  in  the 
anterior  layer.  The  posterior  surface  often  appears  crenated,  in  which 
case  the  cells  look  wedge  shaped,  with  their  apices  pointing  forwards. 
At  the  pupillary  edge  the  layers  fuse,  and  this  represents  the  mouth  of 
the  secondary  optic  vesicle. 

Fuchs  divides  the  iris  into  two  parts,  the  pupillary  zone,  central  to 
the  circulus  minor,  and  the  ciliary  zone,  peripheral  to  it ;  the  latter 
being  further  subdivided  from  within  out  into  (i)  a  smooth  part,  (2) 
a  folded  part,  with  i — 7  concentric  contraction  (or  rather,  dilatation) 
furrows,  and  (3)  a  very  narrow  marginal  zone,  seen  only  in  blue  eyes, 
especially  in  children,  as  a  black  circle  close  to  the  root.  This  zone 
has  numbers  of  very  small  crypts.  These  zones,  and  the  microscopic 
structure  of  the  iris,  vary  with  the  conditions  of  contraction  or  dilata- 
tion ;  and  important  changes  in  the  relation  of  the  root  of  the  iris  to 
the  angle  of  the  anterior  chamber  also  occur. 

The  meshes  of  the  ligamentum  pectinatum  are  normally  elongated 
in  a  meridional  direction.  Heine  has  shown  in  monkeys'  eyes  that  in 
atropin  mydriasis  the  meshes  collapse,  whilst  in  eseriri  miosis  they  are 
opened  out. 

In  miosis  the  pupillary  zone  is  stretched  and  increased,  the  crypts 


286  THE    PATHOLOGY    OF   THE    EYE 

are  pulled  out  into  radial  slits,  and  the  furrows  are  flattened  out. 
The  retinal  layer  is  pulled  farther  forwards,  so  that  there  is  a  physio- 
logical ectropion  of  the  pigment  layer  (Grunert).  The  iris  is  thinned, 
the  section  of  the  sphincter  is  elongated  and  brought  parallel  to  the 
pigment  layer,  its  pupillary  third  being  slightly  bowed  forwards  (Fuchs). 
The  retinal  epithelium  is  flattened. 

In  mydriasis  the  pupillary  zone  is  narro\ved  and  folded  in,  so  that 
it  forms  a  cup;  the  pigmented  border  becomes  thin  and  may  disappear. 
The  ciliary  zone  is  narrowed  and  thrown  into  concentric  folds,  the 
summits  of  which  approach  nearer  to  the  back  of  the  cornea,  and  may 
nearly  touch  it.  The  microscopical  appearances  are  difficult  to  obtain, 
since  artificial  mydriasis  soon  passes  off  after  removal  of  the  eye.  If 
enucleated  during  atropin  mydriasis  and  plunged  into  warm  Fleming's 
solution  (Heine),  the  iris  is  seen  to  be  thickened,  so  as  to  be  club- 
shaped,  and  the  pigment  epithelium  is  crowded  together  so  that  the 
cells  are  elongated  and  ride  over  one  another. 

RocHON-DuviGNEAUD. — Rechcrches  anat.  et  clin.  sur  le  Glaucome,  Paris,  1898. 
TREACHKR  COLLINS. — Trans.  IX  Internat.  Congress,  Utrecht,  1899.  PARSONS. — T.  O.  S., 
xxii,  1902.  ASAYAMA. — A.  f.  O.,  liii,  i,  1901.  v.  MICHEL. — A.  f.  O.,xxvii,  2,  1881.  *FUCHS. 
— A.  f.  O.,  xxxi,  3,  1885.  JULER. — Trans.  Internat.  Congress,  Edinburgh,  1894.  GRUNERT. 
—A.  f.  A.,  xxxvi,  1898.  STOCK.— K.  M.  f.  A.,  xl,  1902.  BAAS.— A.  f.  O.,  xlv,  3,  1898. 
HEINE. — A.  f.  O.,  xlix,  i,  .1900.  *SziLi,  JR. — A.  f.  O.,  liii,  3,  1902.  GUTMANN. — Z.  f.  A.,  x, 
1903.  VERHOEFF. — R.  L.  O.  H.  Rep.,  xv,  4, 1903.  *PARSONS. — R.  L.  O.  H.  Rep.,  xvi,  i,  1904. 


WOUNDS 

In  a  wound  of  the  iris  the  tissue  retracts  and  the  wound  gapes,  the 
aperture  being  usually  filled  with  blood-clot,  which  later  forms  a  granular 
mass  in  which  fibres  may  be  seen.  There  is  little  or  no  formation  of 
granulation  tissue  unless  the  iris  is  prolapsed  and  exposed;  consequently 
also  there  is  no  formation  of  true  scar  tissue. 

In  iridectomy  the  iris  is  usually  already  degenerated,  and  this  may 
account  for  the  lack  of  cicatricial  reaction.  The  edges  are  generally  a 
little  thickened,  and  are  later  pulled  backwards  by  the  contraction  of 
the  posterior  layers. 

Treacher  Collins  has  described  a  recent  iridectomy  in  which  there 
was  a  large  haemorrhage  into  the  substance  of  the  iris,  and  Descemet's 
membrane  was  stripped  up  from  the  cornea  by  blood. 

Uncomplicated  wounds  of  the  iris  have  received  scant  attention, 
and  it  is  probable  that  important  facts  might  be  discovered  by  re- 
investigation. 

TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xiii,  1890. 


INFLAMMATION 
ACUTE  IRITIS 

Acute  iritis  has  been  studied  experimentally  by  v.  Michel,  and  the 
results  are  confirmed  by  the  condition  found  in  the  iris  in  human  eyes 


THE    IRIS   AND    ANTERIOR    CHAMBER 


287 


removed  on  account  of  perforating  wounds  and  ulcers,  etc.  Iritis  is 
best  studied  in  albino  rabbits,  in  which  the  anterior  chamber  is 
first  emptied  of  aqueous  and  then  injected  with  £ — £  per  cent,  silver 
nitrate  solution.  The  iritis  is  present  after  six  hours,  and  v.  Michel 
examined  the  eyes  after  six,  eight,  twelve,  and  twenty-four  hours.  He 
found  extensive  upheaval  of  the  endothelial  layer  by  fibrinous  coagulum, 
which  varied  much  in  breadth.  The  fibrin  formed  a  fine  network,  in 
the  meshes  of  which  were  leucocytes ;  these  often  ran  together  into 
clumps.  In  places  the  endothelium  was  destroyed,  and  the  fibrinous 
coagulum  extended  into  the  anterior  chamber  and  into  the  pupillary 
area,  as  well  as  deep  down  into  the  iris  stroma  itself.  It  also  passed  on 
to  the  posterior  surface  of  the  iris  and  into  the  posterior  chamber. 


FIG.  186. — PLASTIC  IRITIS,      x    120. 

The  iris  is  covered  by  a  delicate  network  of  fibrin,  which  also  passed  across  the 
pupil ;  it  is  rather  indistinct  in  the  figure.  The  blood-vessels  of  the  iris  are  dilated 
and  packed  with  red  corpuscles  ;  the  stroma  is  much  infiltrated,  especially  in  the 
anterior  layers. 

Similar  appearances  are  found  in  the  human  eye.  The  blood- 
vessels are  dilated,  packed  with  red  corpuscles  and  leucocytes,  the 
latter  being  more  numerous  than  in  the  normal  state.  It  has  not  been 
proved  that  new  vessels  are  formed,  though  it  is  probable.  Those 
frequently  described  as  such  clinically  occur  chiefly  in  new  fibrous 
tissue,  though  some  are  probably  merely  very  dilated  normal  vessels. 

There  may  be  haemorrhages,  but  these  are  commonest  in  septic 
iritis.  The  iris  stroma  is  distended  with  exudate  and  infiltrating  cells 
(Fig.  186).  The  latter  consist  of  lymphocytes,  polymorphonuclear 
leucocytes,  and  mast-cells  ;  the  last  named  are  often  present  in  large 
numbers.  The  exudate  may  be  free  from  fibrin,  but  this  often  forms  a 


288  THE    PATHOLOGY    OF   THE    EYE 

well-marked  network.  In  any  case  it  pervades  the  stroma,  often  also 
separating  the  retinal  pigment  layers,  and  extends  generally  into  the 
anterior  chamber  and  pupillary  area.  Whether  that  found  in  the 
posterior  chamber  is  derived  from  the  iris  or  from  the  ciliary  body  is 
uncertain,  but  the  latter  source  is  the  more  probable,  the  ciliary  body 
almost  invariably  partaking  more  or  less  in  the  inflammatory  process, 
at  any  rate  in  eyes  which  are  subjected  to  microscopical  examination. 
Fibrinous  coagula  do  not  always  raise  the  endothelium,  as  stated  by 
v.  Michel.  They  often  cover  it,  and  descend  into  the  crypts  (Fig.  186). 
The  endothelium  often  proliferates,  especially  near  the  pupillary  border, 
and  this  doubtless  aids  the  formation  of  synechise. 

The  pigment  epithelium  is  often  broken  up  in  various  ways,  so  that 


FIG.  187. — BOMBE  IRIS,      x    10.5. 

Very  extensive  peripheral  anterior  synechia  ;  posterior  synechia  with  seclusio 
pupillae  ;  inflammatory  pupillary  membrane  with  occlusio  pupillae ;  anterior  capsular 
cataract. 

cystic  spaces  are  formed  between  the  two  layers  ;  these  may  be  empty 
or  filled  with  fibrin  and  cells,  debris,  etc.  They  occur  chiefly  near  the 
pupil  or  near  the  ciliary  body.  Some  of  the  cells  often  swell  and  are 
cast  off,  either  into  the  iris  stroma  or  from  the  free  surface.  Many  lose 
much  of  their  pigment,  free  granules  being  found  between  the  cells, 
in  leucocytes,  in  the  anterior  chamber,  etc.  Clumps  of  pigment  are 
seen  in  cells  in  the  iris  stroma  ;  these  are  possibly  displaced  epithelial 
cells,  but  probably  most  are  contained  in  leucoytes. 

Best  has  demonstrated  the  presence  of  globules  of  glycogen  in  the 
exudates  in  the  tissue  in  iritis. 

The  fibrinous  exudate  soon  ties  down  the  pupillary  edge  of  the 
iris  to  the  anterior  capsule  of  the  lens,  and  organisation  seems  to  begin 


THE    IRIS   AND    ANTERIOR   CHAMBER  289 

here  very  early,  resulting  in  the  formation  of  permanent  posterior 
synechiae  (Fig.  188).  Even  when  the  iris  becomes  subsequently  free,  the 
posterior  layer  of  pigment  often  remains  stuck  to  the  lens  ;  the  anterior 
layer  is  much  more  intimately  attached  to  the  stroma  and  is  torn  from 


FIG.  188. — SECLUSIO 
From  Lavvson,  after  Priestley  Smith. 

the  lens.  There  may  be  an  active  proliferation  of  the  retinal  epithelium, 
but  this  is  rarely  a  marked  feature. 

Usually,  when  the  synechia  gives  way,  the  posterior  layer  of  pig- 
ment remains  upon  the  lens  capsule,  and  is  torn  away  entirely  from  the 
iris  ;  it  gradually  atrophies,  but  remnants  often  remain  permanently. 
In  other  cases  it  is  not  wholly  separated  from  the  iris,  but  the  two 
layers  of  pigment  epithelium  are  torn  apart,  and  cystic  spaces  are  pro- 
duced (v.  infra.). 

If  the  whole  circle  of  the  pupil  is  tied  down  to  the  lens,  an  annular 
or  ring  synechia  is  produced,  and  the  anterior  chamber  is  shut  off  from 
the  posterior  (seclusio  pupillce) .  This  condition  is  full  of  danger  for  the 
eye,  leading  later  to  iris  bombe  (Fig.  187),  the  accumulation  of  fluid 
behind  the  iris  causing  it  to  become  bulged  forward  like  a  sail,  so  that 
it  looks  crateriform  from  in  front.  In  this  manner  the  periphery  is 
pressed  against  the  cornea  and  may  become  adherent ;  in  any  case 
secondary  glaucoma  results  unless  the  condition  is  relieved.  Sometimes 
the  exudate  in  the  posterior  chamber  organises  entirely.  The  back  of 


FIG.  189. — OCCLUSIO 
From  Lawson,  after  Priestly  Smith. 

the  iris  is  then  tied  down  to  the  lens  over  its  whole  area,  and  a  total 
posterior  synechia  results  (Fig.  190).  The  exudate  in  the  pupillary  area, 
again,  may  organise,  an  inflammatory  pupillary  membrane  being 
formed;  in  this  manner  the  pupil  is  closed  (occlnsio pupilla)  (Fig.  189). 

In  mild  cases  of  iritis  the  exudate  is  entirely  absorbed,  and  little  or 
no  anatomical  evidence  of  previous  inflammation  may  remain.     When 

19 


2go 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  190. — TOTAL  POSTERIOR  SYNECHIA.      x    7. 

Irido-cyclitis,  commencing  phthisis  bulbi.  Total  posterior  synechia,  retraction 
of  periphery  of  iris  ;  occlusio  pupillse  by  delicate  pupillary  membrane.  Anterior 
capsular  cataract,  calcareous  down  and  to  the  left.  Degeneration  of  ciliary  body 
and  detachment  of  posterior  part.  Complete  detachment  of  retina. 


FIG.  191. — FIBROUS  TISSUE  ON  IRIS,      x    55. 

From  a  microcephalic  idiot,  set.  6;  irido-cyclitis  with  detached  retina,  c, 
posterior  lamellae  of  cornea ;  note  k.  p.  with  pigment-cells  on  left,  hyaline  nodule 
with  pigment-cells  on  right ;  I,  iris,  inflamed  and  degenerated,  showing  fibrinous 
networks  in  places ;  F,  laminated  fibrous  tissue,  as  thick  as  the  cornea,  nearly  fill- 
ing the  anterior  chamber. 


THE    IRIS   AND    ANTERIOR   CHAMBER  291 

organisation  takes  place,  as  in  more  chronic  cases,  and  where  more 
fibrinous  exudates  are  poured  out,  the  fibrin  is  transformed  into  young 
vascular  connective  tissue,  which  forms  a  layer  upon  the  surface  of  the 
iris.  The  tissue  is  at  first  rich  in  cells,  doubtless  derived  from  the  fixed 
connective-tissue  cells,  and  these,  with  proliferated  capillaries,  invade 
the  exudates  which  fill  the  pupil  and  cover  the  surface  of  the  iris.  The 
cells  form  fibrous  tissue,  and  the  number  of  nuclei  diminishes,  only  a 
few  spindle-shaped  cells  eventually  persisting  between  the  dense 
bundles  of  fibres.  This  layer  of  tissue  varies  much  in  thickness,  being 
usually  thin,  but  occasionally  very  thick  (Fig.  191).  In  the  latter  cases 
it  is  often  arranged  in  definite  layers,  the  deeper  being  more  fibrous 
and  less  cellular  than  the  superficial ;  this  is  due  to  recurrent  attacks, 
with  the  deposition  of  fresh  layers.  A  few  blood-vessels  and  groups  of 
lymphocytes  often  persist  almost  indefinitely  in  the  fibrous  tissue. 

The  inflammatory  pupillary  membrane  produced  by  the  organisation 
of  exudate  filling  the  pupil  varies  greatly  in  nature  and  consistency.  It 
often  forms  an  extremely  delicate  web,  composed  of  embryonic  con- 
nective tissue  carrying  a  few  capillaries  with  endothelial  walls  (Fig.  190) . 
In  other  cases  it  is  thick  and  dense,  highly  cellular  and  vascular  at 
first,  but  later  composed  of  fibrous  tissue  with  few  cells  and  few  or  no 
blood-vessels.  All  gradations  between  these  two  conditions  are  met 
with.  When  resulting  from  perforating  wounds  or  ulcers,  bands  or 
filaments  of  fibrous  tissue  often  stretch  from  the  iris  or  pupillary 
membrane  to  the  corneal  scar,  having  been  more  or  less  stretched 
out,  according  to  their  consistency,  when  the  anterior  chamber  was  re- 
established. 


CHRONIC  IRITIS 

Chronic  iritis  assumes  different  forms.  In  its  simplest  form  there  is 
no  exudate,  but  some  granulation  tissue  or  new-formed  fibrous  tissue. 
There  are  often  thickenings  of  the  iris  in  places,  and  here  nodules  are 
formed  of  aggregations  of  lymphocytes  (see  "Nodular  Iritis") ;  polymor- 
phonuclear  leucocytes  are  generally  absent.  The  blood-vessels  show 
often  marked  changes.  They  are  frequently  surrounded  by  round-celled 
infiltration,  and  are  themselves  degenerated,  showing  peri-  and  end- 
arteritis.  The  adventitia  often  forms  a  thick  hyaline  ring  in  section, 
and  the  endothelium  of  the  intima  has  disappeared.  Frequently  the 
smaller  vessels  are  blocked  by  the  proliferation  of  endothelium  and 
endarteritis  obliterans,  or  by  hyaline  degeneration.  Such  changes  are 
frequent  in  syphilitic  iritis  (q.  v.). 

In  old  cases  of  chronic  iritis  the  iris  is  usually  atrophic  (v.  infra). 

Chronic  iritis  is  often  associated  with  cyclitis,  and  in  many  of  these 
cases  hyperplasia  of  the  tissues  occurs.  The  endothelium  is  much 
thickened,  forming  several  layers  (Fig.  199).  The  nuclei  may  be  re- 
tained, but  more  frequently  hyaline  changes  take  place  and  homo- 
geneous warty  nodules  are  seen,  such  as  are  found  on  Descemet's 
membrane.  The  vessels  show  thickened  adventitia,  and  often  endar- 
teritis. 


2Q2 


THE    PATHOLOGY    OF   THE    EYE 


NODULAR  IRITIS 

Nodular  (or  pseudo-tubercular)  iritis  includes  a  variety  of  conditions 
in  which  the  common  feature  is  the  formation  of  nodules,  produced  by 
aggregations  of  lymphocytes,  with  or  without  endothelial  and  giant- 
cells.  They  never  caseate. 

Nodular  clumps  of  leucocytes  in  the  iris,  ciliary  body,  and  choroid 
are  often  the  only  microscopical  evidence  of  sympathetic  ophthalmia 
in  either  the  exciting  or  the  sympathising  eye  (Schirmer  and  others). 

They  also  occur  in  chronic  iritis  from  various  causes,  e.  g.  syphilis 


FIG. 


IRITIS. 


60. 


192. — 

Chronic  irido-cyclitis  following  influenza.  Nodular  aggregation  of  lymphocytes 
near  pupillary  margin  of  iris  ;  there  were  spherical  hyaline  globules  in  the  stroma 
of  this  iris.  Note  inflammatory  pupillary  membrane. 

(Fuchs),  leucaemia  (v.  Michel),  etc.,  usually  some  general  diathesis  (Fig. 
192).  They  may  here  be  accompanied  by  epithelioid  and  giant-cells, 
and  Vossius  describes  a  sort  of  capsule  of  fibrous  tissue,  with  spindle- 
cells  derived  from  the  adventitia  of  blood-vessels. 

v.  Michel  found  microscopic  nodules,  with  epithelioid  cells,  arranged 
along  the  blood-vessels,  like  tubercles  of  the  pia  mater.  Some  of  these 
cases  are  probably  true  tubercular  iritis. 

The  typical  pseudo-tubercular  nodule  in  the  iris  is  caused  by  certain 
caterpillar  hairs,  like  that  found  in  the  conjunctiva.  In  this  case  giant- 
cells  are  formed  by  the  irritation  set  up  by  the  hairs,  and  they  are 
surrounded  by  epithelioid  cells  and  leucocytes  (v.  p.  84). 


THE    IRIS    AND   ANTERIOR   CHAMBER  293 

PURULENT  IRITIS 

Purulent  iritis  occurs  by  direct  infection  or  as  a  feature  of  metas- 
tatic  ophthalmitis.  It  is  distinguished  by  widespread  necrosis  of  the 
tissues,  affecting  also  the  blood-vessels,  with  the  result  that  extensive 
haemorrhages  are  found. 

v.  Michel  found  a  great  number  of  bacterial  thrombi  in  the  smaller 
arteries  in  a  case  of  septicaemia.  The  vessels  were  blocked  with  fibrin, 
pus,  and  masses  of  cocci.  The  veins  were  dilated  and  packed  with  red 
corpuscles,  and  the  surrounding  stroma  was  filled  with  red  corpuscles. 


FIG.  193. — PURULENT  IRITIS  AND  CYCLITIS.      x   55. 

Perforating  wound,  panophthalmitis.  The  anterior  part  consists  of  pus  and 
blood  in  the  a.  c.  The  iris  is  intensely  congested,  densely  infiltrated  with  poly- 
morphonuclear  leucocytes,  and,  to  the  left,  quite  necrotic.  The  ciliary  processes 
on  the  right  below  are  in  the  same  condition  as  the  iris,  and  are  covered  by  a  mass 
of  fibrin  and  pus,  which  extends  into  the  vitreous. 

Suppurative  iritis  is  most  commonly  seen  in  specimens  of  panoph- 
thalmitis following  perforating  wounds  or  ulcers  (Fig.  193).  The  organ- 
isms cannot  often  be  demonstrated,  though  in  other  cases  they  are 
present  in  great  numbers.  They  may  increase  after  the  removal  of  the 
eye,  though  this  can  seldom  occur  in  eyes  with  perforation  placed  at 
once  in  formol.  The  iris  is  usually  thickened  and  filled  with  pus-cells, 
which  also  fill  the  anterior  chamber,  so  that  the  exact  limits  of  the  iris 
are  masked.  The  pigmented  stroma  cells  are  swollen,  and  their  nuclei 
stain  badly.  Granules  of  pigment  are  scattered  throughout  the 
tissues,  being  both  intra-  and  extra-cellular ;  they  are  aggregated  into 
irregular  clumps  in  places.  The  vessel-walls  are  much  altered,  the 


294  THE    PATHOLOGY   OF   THE    EYE 

cells  being  swollen  and  indefinite,  often  homogeneous.  Sometimes  the 
tissues  are  quite  necrotic,  so  that  the  nuclei  no  longer  stain,  except 
those  of  the  invading  polymorphonuclear  leucocytes. 

v.  MICHEL. — A.  f.  O.,  xxvii,  2,  1881.     ULRICH. — A.  f.  O.,  xxviii,  2,   1882.     SCHIRMER. 
— A.  f.  O.,  xxxviii,  4,  1892  ;  and  in  G.-S.,  2nd  ed.,  1900.     Vossius. — B.  z.  A.,  ii,  1891. 


SYPHILIS 

Syphilitic  iritis  has  been  investigated  by  v.  Michel,  v.  Hippel, 
Fuchs,  and  others.  It  resembles  the  ordinary  forms  of  chronic  iritis, 
from  which  it  cannot  be  distinguished  microscopically,  v.  Miche, 
examined  portions  of  iris  removed  by  iridectomy  ;  he  found  marked 
endarteritis  of  the  smaller  vessels,  which  were  often  blocked  by  the  pro- 
liferated endothelial  cells.  The  vessel-wall  was  homogeneous,  and  the 
cells  of  the  adventitia  had  proliferated  and  formed  a  thick  ring.  These 
changes,  however,  are  not  specific,  and  were  slight  or  absent  in  cases 
examined  by  Scherl  and  Benoit.  v.  Michel  and  Fuchs  described 
microscopic  nodules,  which  could  not  be  seen  clinically.  Fuchs  found 
the  iris  of  normal  thickness,  infiltrated  with  round-cells,  chiefly  in  the 
anterior  limiting  zone.  The  nodules  usually  occupy  the  root  of  the 
iris,  and  include  the  whole  thickness;  they  fade  off  into  the  surrounding 
tissue.  They  often  break  through  the  anterior  surface  and  communi- 
cate with  the  anterior  chamber.  They  consist  chiefly  of  mononuclear 
cells  embedded  in  a  fine  reticulum.  Fuchs  found  typical  giant-cells, 
but  no  caseation.  There  were  wide  capillaries  inside  the  nodules,  which 
differ  thus  from  the  non-vascular  tubercle  nodules. 

This  and  the  similar  condition  described  by  Baas  may  be  of  the 
condylomatous  type,  but  it  is  usually  impossible  to  distinguish  condy- 
lomata  from  gummata  (see  "Ciliary  Body").  Barensprung  considered 
simple  syphilitic  iritis  to  belong  to  the  secondary  stage,  the  nodules 
being  gummatous  (iritis  gummosa).  Widder,  from  clinical  considera- 
tions, thought  that  nodules  were  frequent  in  the  secondary  stage  (iritis 
condylomatosa  or  papulosa),  and  that  true  gummata,  although  they 
occurred,  were  extremely  rare.  It  is  noteworthy  that  the  "condylo- 
matous" nodules  are  found  in  the  sites  which  are  also  favoured  by 
gummata.  Fuchs  considers  that  microscopic  nodules  are  almost  con- 
stant in  syphilitic  iritis. 

Gumma  of  the  iris  is  usually  solitary,  and  forms  a  yellow  or 
brownish-red  tumour  with  few  vessels  visible  upon  it,  thus  differing 
from  typical  sarcoma  of  the  iris.  It  occurs  by  preference  at  the 
pupillary  or  the  ciliary  edge,  and  generally  sets  up  comparatively  little 
inflammatory  reaction.  Virchow  and  Billroth  record  the  first  anatomical 
examination.  The  tumour  was  removed  from  a  child  aged  one  year, 
and  consisted  of  granulation  tissue  with  giant-cells  and  some  fatty 
degeneration ;  it  was  possibly  tubercular.  Colberg  found  masses  of 
round-cells,  with  many  new-formed  capillaries,  in  a  gumma  removed 
by  iridectomy.  Similar  results  were  recorded  by  v.  Hippel  and 
Neumann. 

More  recently  gummata  of  the  iris  have  been  examined  by  Scherl, 


THE    IRIS   AND    ANTERIOR   CHAMBER  295 

Benoit,  and  Rumschewitsch,  whilst  more  extensive  tertiary  syphilitic 
disease  of  the  uveal  tract  has  been  described  by  Baas,  Hanke,  Fialho, 
and  de  Schweinitz.  Scherl's  case  was  distinguished  by  extensive 
caseation  and  necrosis,  the  iris  tissue  having  disappeared  and  been 
replaced  by  inflammatory  deposits,  the  cells  of  which  had  broken  down 
into  granular  debris,  which  also  pervaded  the  anterior  chamber.  In 
Benoit's  case  there  was  also  much  destruction  of  tissue,  with  the  pro- 
duction of  a  cavity  which  contained  a  few  pus-cells.  Surrounding  this 
was  tissue  containing  giant-cells,  epithelioid  and  round  cells,  and  pigment 
granules.  The  giant-cells  were  partly  of  the  Langhans  type,  the 
nuclei  being  arranged  around  the  pheriphery ;  in  others  the  nuclei  were 
central.  In  the  anterior  part  of  the  tumour  were  many  new-formed 
blood-vessels,  consisting  of  endothelial  tubes  with  wide  lumina.  Some 
of  the  iridic  vessels  were  obliterated  by  endarteritis. 

Rumschewitsch's  case,  unlike  the  others,  occurred  definitely  in  the 
tertiary  stage.  The  gumma  was  oval,  3  mm.  in  diameter.  The  centre 
was  structureless  apart  from  a  few  fine  granules  ;  it  did  not  stain,  and 
the  periphery  stained  only  faintly.  It  was  separated  from  the  lens 
capsule  by  a  thick  layer  of  irregular  pigment  granules.  At  the 
periphery  there  were  small  cells,  and  there  was  a  capsule  around  the 
tumour  consisting  of  concentrically  arranged  spindle-cells.  A  little 
below  the  surface  the  intercellular  substance  was  hyaline.  Degenerated 
and  obliterated  vessels  could  be  made  out  at  the  periphery  best  in 
specimens  stained  with  thionin  and  eosin.  There  were  no  giant-cells. 

Similar  descriptions  are  given  by  Baas,  Hanke,  and  Fialho  (v.  infra.}. 

VIRCHOW  AND  BILLROTH. — See  v.  GRAEFE,  A.  f.  O.,  vii,  2,  1860.  A.  GRAEFE  AND 
COLBERG.— A.  f.  O.,  viii,  i,  1861.  v.  HIPPEL. — A.  f.  O.,  xiii,  i,  1867.  *WIDDER. — A.  f.  O., 
xxvii,  2,  1881.  MICHEL. — A.  f.  O.,  xxvii,  2,  1881.  FUCHS. — A.  f.  O.,  xxx,  3,  1884. 
BARLOW. — Trans.  Path.  Soc.,  xxvii.  LIEBRECHT. — K.  M.  f.  A.,  xxix,  1891.  SCHERL. — 
A.  f.  A.,  xxv,  1892.  *BAAS—  A.  f.  O.,  xlv,  3,  1898.  BENOIT  —  A.  d'O.,  xviii,  1898. 
RUMSCHEWITSCH. — K.  M.  f.  A.,  xli,  1903.  HANKE. — A.  f.  O.,  xlviii,  1899.  FIALHO. — 
A.  f.  O.,  lii,  3,  1901.  DE  SCHWEINITZ. — Ophth.  Rev.,  xix,  1900. 


TUBERCLE 

Tubercle  of  the  iris  occurs  in  three  chief  forms  : 

1.  \Iiliary  tubercle,  characterised  by  a  variable  number  of  yellow 
nodules ;  it  is  often  relatively  benign,  including  Leber's  group  of  cases 
of  attenuated  tubercle. 

2.  Confluent  or  conglomerate  tubercle,  characterised  by  definite  tumour 
formation,  composed  of  various  forms  of  granulation  tissue,  which  in- 
vades a  greater  or  less  part  of  the  anterior  chamber,  tends  to  increase 
rapidly  and  destroy  the  eye,  as  well  as  leading  to  general  dissemination. 

3.  Tubercular  iritis,  usually  indistinguishable  clinically  from  other 
forms  of  chronic  iritis,  e.  g.  syphilitic,  but  sometimes   distinguished 
microscopically  by  the  nature  of  the  infiltration,  the  presence  of  tubercle 
systems  and  tubercle  bacilli,  and  experimentally  by  inoculation  results. 

The  first  two  groups  were  differentiated  by  Haab  (1879) ;  the  third 
includes  cases  first  described  by  Costa  Pruneda  (1880),  and  Edmunds 
and  Brailey  (1881).  Gradenigo  (1869)  and  Berthold  (1871)  first  re- 


296 


THE    PATHOLOGY   OF   THE   EYE 


ported  cases  of  tubercle  of  the  iris,  giving  microscopical  examinations  ; 
Perls  (1872)  gave  a  good  clinical  description.  Saltini  (1875),  Manfredi 
(1876),  Baumgarten  (1877),  Weiss  (1877),  and  Angelucci  (1877)  followed 
with  new  cases ;  and  Haensell  (1877),  Cohnheim  (1879),  and 
v.  Michel  (1881)  investigated  the  subject  experimentally.  Since  then 
numerous  papers  have  appeared,  the  most  important  of  which  will  receive 
mention. 

In  miliary  tubercle  of  the  iris  nodules  are  scattered  over  its  surface 
in  varying  numbers,  usually  at  a  little  distance  from  the  pupillary  edge, 
near  the  circulus  arteriosus  minor,  or  in  the  angle  of  the  anterior 
chamber.  In  each  case  there  is  a  tendency  for  the  iris  to  be  most 
affected  in  the  lower  part  (Angelucci,  Zimmermann,  Schultze).  The 


FIG.  194. — TUBERCULAR  IRITIS,      x    10. 

From  a  specimen  sent  by  Prof.  Fuchs.  The  iris  is  thickened  by  granulomatous 
infiltration.  Note  the  deep  parenchymatous  infiltration  of  the  cornea  (tubercular 
interstitial  keratitis).  This  consists  of  dense  infiltration  of  the  deep  lamellae  with 
leucocytes  ;  Descemet's  membrane  is  split  up  and  ruptured. 

nodules  are  usually  yellow,  and  it  is  by  no  means  uncommon  for  them 
to  have  vessels  upon  the  surface.  As  they  grow  and  fuse  they  become 
greyish  red  ;  they  may  fill  the  whole  posterior  part  of  the  anterior 
chamber  (Fig.  194),  invading  the  ciliary  body  and  corneo-scleral  margin. 
The  cornea  becomes  infiltrated  in  its  deeper  part,  showing  a  tubercular 
type  of  interstitial  keratitis  (v.  p.  191),  and  may  contain  tubercle  systems. 
The  corneo-scleral  margin  may  be  perforated  (Fig.  195),  in  which  case 
phthisis  bulbi  usually  supervenes  slowly  (Haab).  In  these  severe 
cases  general  dissemination  may  take  place,  the  patient  dying  of  miliary 
tuberculosis. 

The  prognosis,  however,  is  not  necessarily  bad.     In  many  cases  the 
nodules  grow  very  slowly,  and  eventually  undergo  complete  absorption. 


THE    IRIS   AND   ANTERIOR   CHAMBER  297 

These  cases  constitute  Leber's  attenuated  tubercle;  they  are  often 
improved  by  iridectomy,  whereas  this  operation  fails  completely  in 
other  cases.  Leber  considers  that  the  relatively  benign  course  is  due 
either  to  attenuated  virulence  of  the  bacilli,  to  the  presence  of  an 
unusually  small  number,  or  to  a  specially  strong  reaction  on  the  part  of 
the  organism ;  which  factor  is  the  most  potent  it  is  impossible  to  say. 
The  cases  may  run  a  benign  course  for  a  prolonged  period  and  then 
suddenly  become  more  acute.  Samelsohn  quotes  a  case  in  a  boy  of  six, 
in  which  miliary  tubercles  of  the  iris  disappeared  entirely,  but  were 
shortly  after  followed  by  pericorneal  injection,  meningitis,  and  death. 
In  another  case  miliary  tubercles  disappeared,  and  were  followed  by  the 
conglomerate  type  and  tubercular  meningitis,  ending  fatally.  The  same 
author  demonstrated  the  relative  immunity  of  a  certain  number  of  rabbits 
when  inoculated  with  generations  of  the  same  strain  of  tubercle,  whilst 
the  virulence  was  found  to  increase  for  the  majority  of  the  animals. 

In  confluent  or  conglomerate  tubercle  there  is  a  definite  yellowish-white 
tumour  upon  the  iris,  though  smaller  nodules  may  also  be  present,  often 
in  the  form  of  satellites  around  the  larger  mass.  The  growth  has  the 
usual  tubercular  structure,  consisting  of  giant-cells  with  epithelioid  and 
round  cells  surrounding  them,  as  in  Swanzy's  case ;  there  is  generally 
extensive  caseation,  in  which  remnants  of  giant-cells  may  be  made  out. 
The  individual  nodules,  which  together  make  up  the  tumour  mass,  are 
united  by  bands  of  dense  lymphocytic  infiltration.  The  intermediate 
tissue  is  extremely  vascular  (Riiter).  Frequently  the  growth  increases 
until  it  fills  the  anterior  chamber  (Schell,  Wadsworth,  Sandford,  etc.). 

This  type  of  tubercle  of  the  iris  has  been  well  investigated  by 
Liebrecht.  Wagenmann  first  pointed  out  that  growth  is  almost 
invariably  forwards,  and  Lagrange  emphasises  the  fact  that  the  ciliary 
muscle  is  rarely  invaded,  so  that  the  supra-choroidal  space  is  protected. 
Hence  perforation  usually  occurs  at  the  angle  before  the  choroid  or 
vitreous  are  implicated  (Fig.  195).  The  extra-bulbar  mass  continues 
to  grow  for  a  time,  but  soon  caseates  and  may  shrink ;  the  whole  eye 
may  also  shrink,  as  the  result  of  the  perforation  (Liebrecht). 

Tubercular  iritis,  i.  e.  chronic  iritis  due  to  tubercle,  is  generally  con- 
sidered to  be  the  rarest  manifestation  of  the  disease  in  the  iris. 
Examples  are  found  in  the  cases  of  Costa  Pruneda,  Edmunds  and 
Brailey,  Knaggs,  Kalt,  and  others,  v.  Michel's  observations  (v.  p.  294) 
must  be  borne  in  mind  when  estimating  the  rarity  of  -the  condition. 
There  is  usually  diffuse  infiltration  of  the  iris,  with  great  thickening  ; 
there  are  usually  many  giant-cells  present,  but  typical  tubercle  systems 
are  less  common  than  in  other  forms.  Necrosis  occurs  later,  and  the 
anterior  chamber  is  sometimes  filled  with  material  resembling  pus 
(e.  g.  Edmunds  and  Brailey's  case). 

The  demonstration  of  tubercle  bacilli  in  tissues  is  seldom  easy,  and 
the  iris  forms  no  exception  to  the  rule.  They  are  usually  to  be  found 
in  small  numbers  after  prolonged  search  ;  occasionally  they  are  present 
in  large  numbers  (Lagrange).  The  most  certain  test  of  the  nature  of 
the  disease  is  afforded  by  inoculation  of  the  rabbit's  or  guinea-pig's 
anterior  chamber  with  a  portion  of  the  material;  but  even  this  may  fail, 
as  in  a  case  recorded  by  Haensell  and  confirmed  by  Leber. 


298 


THE    PATHOLOGY    OF   THE   EYE 


Experimental  tubercle  of  the  iris  was  first  studied  by  Haensell  and 
Cohnheim,  subsequently  by  v.  Michel  and  many  others.  Cohnheim 
showed  that  tubercular  material  introduced  into  the  anterior  chamber 
led  to  tuberculosis  of  the  iris,  usually  followed  by  general  infection. 
The  latent  period  varies  greatly — from  a  few  weeks  to  several  months. 
v.  Michel  examined  tubercle  of  the  iris  induced  in  rabbits  by  inoculation 
with  caseous  bronchial  glands,  etc.  He  found  the  endothelium  raised 
when  the  tubercles  were -superficial,  but  unaltered  when  they  lay  deeper 
in  the  stroma.  Giant-cells  were  not  common,  but  when  they  occurred 
they  were  surrounded  by  concentric  layers  of  epithelioid  cells.  Near 
the  nodules  were  often  exudates  and  clumps  of  pigment,  and  prolifera- 
tion of  endothelium  was  more  or  less  general  throughout  the  iris.  The 


FIG.  195. — TUBERCULAR  IRITIS,      x    8. 

From  a  specimen  sent  by  Prof.  Fuchs.  There  is  a  typical  tubercle  near  the 
pupillary  margin  of  the  iris  on  the  right.  On  the  left  the  iris  has  prolapsed  through 
a  tubercular  perforation  at  the  limbus.  It  forms  a  huge  granulomatous  mass  out- 
side the  globe. 

anterior  chamber  contained  afibrinous  coagulum,  with  leucocytes  in  the 
meshes. 

Much  discussion  has  arisen  as  to  whether  tubercle  of  the  iris  is 
primary  or  secondary.  Many  authors,  including  Leber,  Fuchs,  and 
de  Wecker  consider  it  invariably  secondary  to  some  focus  elsewhere  in 
the  body.  Cases  in  which  intra-ocular  tuberculosis  has  been  considered 
primary  have  been  reported  by  a  great  number  of  authors,  including 
Parinaud  (1879),  Samelsohn,  Poncet,  Alexander,  Lawford,  Bach,  etc., 
and  the  view  that  it  is  generally  primary  has  been  ably  upheld  by 
Denig.  This  author  gives  six  tables  :  (i)  38  cases  in  which  there  was 
no  tuberculosis  before,  and  in  which  the  patients  were  otherwise 
absolutely  healthy  at  the  time  of  the  ocular  affection  ;  (2)  14  cases  with 


THE   IRIS   AND   ANTERIOR   CHAMBER  299 

a  tubercular  history,  but  healthy  before  and  during  the  attack ;  (3) 
3  cases  with  earlier  signs  of  tubercle,  healthy  at  the  time  of  the  attack  ; 
(4)  17  cases  of  ocular  tuberculosis  coinciding  with  tuberculosis  in 
other  organs  ;  (5)  9  cases  which  succumbed  to  general  infection  ;  (6) 
10  cases  in  which  the  patients  remained  healthy  after  the  disappearance 
of  the  ocular  affection.  Denig  found  only  5  cases  of  ocular  metas- 
tasis in  60  cases  of  tuberculosis  of  the  lungs,  90  of  the  bones  and  joints, 
20  of  the  lymphatic  glands  in  other  parts  of  the  body.  These 
results  are  confirmed  by  statistics  of  tubercle  of  the  bones  collected 
by  Konig.  In  72  cases  of  tubercle  of  the  conjunctiva  there  were  no 
other  signs  of  the  disease  in  52.  According  to  Denig,  therefore, 
tubercle  in  the  eye  resembles  that  in  the  lungs  and  bones  in  being 
often  the  primary  seat  of  the  disease  ;  moreover  metastasis,  as  also  in 
these  organs,  is  relatively  rare.  The  question  is  obviously  one  of 
extreme  importance  as  a  guide  to  treatment. 

On  the  other  hand,  the  occurrence  of  cases  of  metastatic  tubercle  of 
the  uveal  tract  can  scarcely  be  doubted,  and  is  probably  by  way  of  the 
blood-vessels.  The  primary  seat  in  these  cases  is  the  lungs  or 
bronchial  glands,  more  rarely  the  peritoneum.  The  difficulty  of 
eliminating  such  sources  of  infection  clinically  is  often  very  great. 

HAAB. — A.  f.  O.,  xxv,  4,  1879.  v.  MICHEL. — A.  f.  O.,  xxvii,  2,  1881.  GRADENIGO. — 
Ann.  d'Oc.,  Ixiv,  1870.  BERTHOLD. — Ann.  d'Oc.,  Ixvi,  1871.  PERLS. — A.  f.  O.,  xix,  i,  1872. 
SALTIM. — Ann.  di  Ott.,  iv,  1875.  MANFREDI. — Ann.  d'Oc.,  Ixxviii,  1876.  *WEISS. — A.  f.  O., 
xxiii,  4,  1877.  ANGELUCCI. — Ann.  d'Oc.,  Ixxxii,  1879.  HAENSELL. — A.  f.  O.,  xxv,  4,  1879. 
COHNHEIM. — Die  Tuberculose  vom  Standpunkte  der  Infectionslehre,  Leipzig,  1879. 
ZIMMERMANN. — A.  f.  O.,  xli,  i,  1895.  SCHULTZE. — A.  f.  A.,  xxxiii,  1896.  LEBER. — 

B.  d.  o.  G.,  1890,  1891,  1893.     SAMELSOHN. — B.  d.  o.  G.,  1893.     SWANZY. — T.  O.  S.,  ii, 
1882.     HILL  GRIFFITH. — T.  O.  S.,  x,  1890.     RUTER. — A.  f.  A.,  x,  1881.     SCHELL,  WADS- 
WORTH. — Tr.  Amer.  O.  S.,  1883.     SANDFORD. — T.  O.  S.,  xiv,   1894.     LIEBRECHT. — A.  f.  O., 
xxxvi,  4,   1890.     COSTA   PRUNEDA. — A.  f.  O.,   xxvi,  3,    1880.     EDMUNDS  AND   BRAILEY. — 
T.    O.    S.,    ii,    1882.      KNAGGS. — T.    O.    S.,    xii,    1892.      KALT. — Soc.    de    Biologic,    1893. 
LAGRANGE. — Tumeurs    de    1'CEil,    i,    Paris,    1901.     PARINAUD. — Soc.    de    Chirurgie,    1879. 
DEUTSCHMANN. — A.  f.  O.,  xxvii,  i,  1881.     PONCET. — Soc.  de  Chirurgie,  1882.     ALEXANDER. 

C.  f.  A.,  viii,  1884.      LAWFORD. — R.  L.  O.  H.  Rep.,  xii,  2,  1888.     BACH. — A.  f.  A.,  xxviii, 
1894.     *DENIG. — A.  f.  A.,  xxxi,  1895  (Bibliography).     ANDREWS.— -T.  Am.  O.  S.,  1896. 

LEPROSY 

Isolated  nodules  do  not  occur  in  the  iris  in  leprosy  (Lie),  but  there 
is  general  infiltration  with  leucocytes  and  bacilli,  the  infection  being 
secondary  to  that  of  the  ciliary  body.  When  fully  developed  the  con- 
dition much  resembles  tubercular  iritis.  The  iris  is  enormously  thickened 
with  granulation  tissue  containing  clumps  of  bacilli,  and  this  partially 
or  completely  fills  the  anterior  chamber.  The  condition  is  distinguished 
from  tubercle  by  the  masses  of  bacilli,  mostly  arranged  like  bundles  of 
cigars,  the  thrombosis  of  lymphatics  by  bacilli,  and  the  absence  of 
typical  tubercle  systems  and  caseation,  though  isolated  giant-cells  may 
occur  (Franke  and  Delbanco). 

PONCET. — Progres  medical,  1888.  JEANSELME  AND  MORAX. — Ann.  d'Oc.,  1898.  (See 
BIBLIOGRAPHY  of  LEPROSY  under  "  Lids,"  "  Cornea.") 


300 


THE    PATHOLOGY   OF   THE   EYE 


DEGENERATIONS 

ATROPHY 

Atrophy  of  the  iris  is  the  result  of  repeated  attacks  of  acute  or  sub- 
acute  iritis,  of  chronic  iritis,  glaucoma,  and  other  conditions  which  lead  to 
degenerative  changes  in  the  eye.  Reference  has  already  been  made  to  the 
formation  of  new  fibrous  tissue  upon  the  surface  of  the  iris  as  the  result  of 
the  organisation  of  exudates  in  plastic  iritis.  This  tissue,  by  its  con- 
traction, leads  to  pressure  and  tension  in  the  neighbouring  stroma,  the 
cells  of  which  degenerate,  first  losing  their  long  ramifying  processes, 


FlG.    Ip6. "  ECTROPION    OF    UVEAL    PlGMENT." 

Photograph  by  Lister,   showing  ectropion  of    the  retinal  pigment  epithelium 
and  of  the  sphincter  iridis. 

and  finally  atrophying  in  large  numbers  entirely.  The  contraction  of 
a  superficial  lamina  of  fibrous  tissue  also  leads  to  deformation  of  the 
iris.  The  pupillary  border  of  the  iris  is  pulled  outwards,  so  that  the 
iris  becomes  bent  upon  itself.  In  this  manner  the  retinal  pigment  layer 
is  dragged  for  a  variable  distance  over  the  anterior  surface,  and  the 
condition  known  as  ectropion  of  the  pigment  layer  is  produced  (Lawford, 
Nettleship).  This  is  particularly  common  in  glaucomatous  eyes  (Knies, 
Birnbacher  and  Czermak)  (Fig.  196).  When  the  distortion  is  more 
pronounced  the  sphincter  takes  part  in  the  process,  so  that  it  appears 
hook-  or  horseshoe-shaped  in  radial  section. 

In  the  majority  of  cases  which  are  examined  microscopically  the  iris 
is  uniformly  degenerated  and  thinned,  and  this  is  most  obvious  at  the 
root,  where  the  iris  is  normally  thinnest.  All  parts  of  the  structure 


THE    IRIS    AND    ANTERIOR    CHAMBER 


301 


FIG.  197. — ATROPHY  OF  THE  IRIS,      x    60. 

From  a  case  of  absolute  glaucoma.  The  iris  is  quite  atrophic.  Near  the 
surface  to  the  left  is  the  sphincter  iridis.  The  blood-vessels  are  scarcely  visible, 
and  the  stroma  is  reduced  to  a  few  straggling,  unequally  pigmented  chromatophores, 
with  a  few  wandering  cells. 


FIG.  198. — NEW-FORMED  VESSEL  ox  THE  IRIS. 

Holmes  Spicer  and  Parsons,  T.  O.  S.,  xxii. 


140. 


302 


THE    PATHOLOGY   OF   THE  EYE 


FIG.  199. — INFLAMED  ATROPHIC  IRIS,      x    60. 

From  a  blind  painful  eye  with  ciliary  staphyloma.  The  figure  shows  the  false 
angle  of  the  anterior  chamber.  Note  the  hyperplasia  of  endothelium  on  surface  of 
iris  and  the  dilated  blood-vessels,  full  of  red  corpuscles. 


FIG.  200. — HYALINE  MEMBRANE  ON  IRIS,      x    120. 

Old  anterior  synechia.  Descemet's  membrane  appears  to  split,  one  branch 
passing  over  the  surface  of  the  iris.  Note  that  it  is  covered  by  a  single  layer  of 
endothelium.  The  iris  is  degenerated  and  densely  pigmented. 


THE    IRIS    AND    ANTERIOR   CHAMBER 


303 


participate  in  the  process.  The  normal  loosely  constructed  stroma 
may  retain  its  spongy  nature,  though  it  is  obvious  that  much  of 
the  tissue  has  disappeared  (Fig.  197).  More  commonly  the  loose 
stroma  is  replaced  by  denser  fibrous  tissue  containing  flattened  cells 
with  stunted  processes,  and  often  clumps  of  pigment.  Most  of  the 
chromatophores  have  been  replaced  by  these  non-pigmented  cells.  The 
muscle-fibres  persist  longer,  so  that  the  sphincter  is  generally  easily 
recognised,  though  also  degenerated,  and  more  or  less  replaced  by 
hyaline  connective  tissue.  The  blood-vessels  often  show  a  high  degree 
of  peri-  and  end-arteritis  (Ulrich),  sections  showing  the  usual  picture  of 
thick  hyaline  rings  enclosing  a  minute  lumen,  which  may  contain 
pigment.  In  other  cases  scarcely  any  vessels  are  to  be  seen,  and  some- 
times the  largest  of  these  are  obviously  vessels  of  inflammatory  new 
formation  (Fig.  198).  In  many  cases  spherical  hyaline  globules,  staining 
deeply  with  eosin,  are  seen  in  the  intercellular  spaces.  They  often 


FIG.  201. — HYALINE  PUPILLARY  MEMBRANE  AND  ANTERIOR  SYNECHIA.      x   60. 

Pannus  degenerativus,  thinning,  and  interstitial  infiltration  and  vascularisation 
of  the  substantia  propria.  A  fine  fibrous  anterior  synechia  is  covered  by  endothelium, 
which  has  passed  on  to  the  iris  and  over  the  pupillary  area,  subsequently  producing 
a  complex  folded  hyaline  membrane. 

occur  in  the  iris  in  anterior  staphylomata  (Sachsalber)  in  conjunction 
with  hyaline  changes  in  the  cornea.  The  globules,  which  vary  in  size 
and  sometimes  form  considerable  concretions  which  may  later  calcify, 
are  scattered  throughout  the  stroma,  and  even  in  the  endothelium  and 
pigment  epithelium. 

The  pigment  epithelium  is  very  resistant,  but  also  shows  degenerative 
changes.  It  may  be  uniformly  thinned,  but  more  often  is  irregular — 
thin  or  absent  in  places,  whilst  aggregated  into  clumps  elsewhere.  In 
high  degrees  of  atrophy  it  has  almost  entirely  disappeared ;  it  is  in  such 
cases  that  a  red  reflex  is  obtained  through  the  iris  with  the  ophthalmo- 
scope, and  I  have  seen  this  condition  in  a  severe  case  of  retinitis 
pigmentosa. 

The  endothelium  may  be  unaltered,  but  is  often  very  much  thickened 
Fig.  199).  Warty  outgrowths  may  be  formed  like  those  upon  Descemet's 
membrane.  The  cells  may  be  well  formed,  with  well-stained  nuclei,  but 
more  frequently  they  .are  degenerated,  possessing  few  or  no  nuclei, 


304  THE    PATHOLOGY   OF   THE   EYE 

being  transformed  into  hyaline  masses.  A  common  phenomenon,  first 
described  by  Wagenmann,  is  the  formation  of  a  hyaline  membrane  upon 
the  surface  of  the  iris  (Fig.  200).  It  occurs  generally  in  glaucomatous 
eyes,  in  which  there  is  a  peripheral  anterior  synechia.  At  the  false 
angle  Descemet's  membrane  is  continued  over  the  iris,  or  appears  to 
split ;  the  endothelium  is  similarly  continued  from  the  back  of  the 
cornea  on  to  the  new  hyaline  membrane,  and  may  even  pass  over  the 
pupillary  border  on  to  the  pigment  epithelium  at  the  back  of  the  iris. 
The  hyaline  membrane  is  usually  thin  (5 — 6  fi),  but  may  have  warty 
excrescences ;  it  is  doubtless  a  secretion  product  of  the  endothelial 
cells. 

LAVVFORD,  NETTLESHIP. — T.  O.  S.,  vi,  1886.  KNIES. — A.  f.  O.,  xxii,  3,  1876. 
BIRNBACHER  AND  CzERMAK. — A.  f.  O.,  xxxii,  2,  1886.  L/LRiCH. — A.  f.  O.,  xxviii,  2,  1892  ; 
xxx,  4,  1884.  WAGENMANN. — A.  f.  O.,  xxxviii,  2,  1892.  GEPNER. — A.  f.  O.,  xxxvi,  4,  1890. 
HARING. — A.  f.  O.,  xliii,  i,  1897.  SACHSALBER. — B.  z.  A.,  xlviii,  1901.  FRANCK. — A.  f.  A., 
xlvii,  1903. 

CALCAREOUS  DEGENERATION  AND  OSSIFICATION 

We  have  already  seen  that  calcareous  deposits  sometimes  occur  in 
the  atrophic  iris.  Rarely  bone  lamellae  are  found,  but  almost  invari- 
ably they  are  formed  by  extension  from  bony  deposits  in  the  choroid. 
Panas  described  a  case  which  he  regarded  as  primary ;  the  iris  was 
found  to  be  bony  in  a  man  of  thirty-six,  upon  whom  an  iridectomy  was 
being  performed.  Microscopic  examination  of  the  fragments  removed 
demonstrated  the  presence  of  osteoblasts. 

PANAS. — Gaz.  des  H6pitaux,  1868. 


THE  ANGLE  OF  THE  ANTERIOR  CHAMBER 

Abnormalities  in  the  angle  of  the  anterior  chamber  occur  in  a  large 
variety  of  pathological  conditions,  and  present  many  different  ap- 
pearances in  microscopical  sections.  Of  these  the  commonest  and 
most  important  is  the  obliteration  of  the  true  angle  by  the  adhesion  of 
the  peripheral  part  of  the  iris  to  the  cornea  over  a  less  or  greater  area 
(Figs.  203 — 5).  This  is  the  condition  found  in  the  great  majority  of 
cases  of  secondary  glaucoma.  Its  importance  was  first  insisted  upon  by 
Knies  and  Weber,  working  independently  in  1876,  and  following  a  clue 
given  three  years  earlier  by  Leber. 

The  earliest  phase  of  obliteration  of  the  angle  is  found  in  simple 
apposition  of  the  periphery  of  the  iris  to  the  cornea,  brought  about  by 
the  physical  conditions  which  induce  the  onset  of  the  glaucoma,  and 
which  will  be  fully  considered  in  discussing  the  general  pathology  of 
this  disease.  The  iris  under  these  circumstances  may  be  normal  or 
inflamed  ;  in  the  latter  case  exudates  are  thrown  out  which  rapidly 
lead  to  actual  adhesion,  and  this  follows  in  any  case  if  the  apposition 
is  sufficiently  prolonged.  Here  the  irritation  induced,  while  insufficient 
to  produce  the  more  marked  anatomical  characteristics  of  inflammation, 


THE    IRIS   AND    ANTERIOR   CHAMBER 


305 


FIG.  202. — NORMAL  ANGLE  OF  ANTERIOR  CHAMBER,      x    34. 
From  a  specimen  by  Lister.     The  eye  was  normal  apart  from  extensive  pig- 
mentation of  the   conjunctiva  and    epithelium    of  the    cornea.      There   are   a  few 
scattered  pigment-cells  upon  the  ligamentum  pectinatum  iridis.     Schlemm's  canal 
is  normal. 


FIG.  203. — PERIPHERAL  ANTERIOR  SYNECHIA.      x   55.  > 

Secondary  glaucoma  from  detached  retina  following  a  blow.  27,  i,  1900,  blow; 
II,  ix,  1900,  detached  retina  seen;  24,  iii,  1902,  inflammation,  T  +  2.  Narrow 
peripheral  anterior  synechia;  the  adherent  iris  is  more  degenerated  than  in  Fig.  204. 
Schlemm's  canal  is  open,  but  surrounded  by  infiltration. 

2O 


3o6 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  204.— PERIPHERAL  ANTERIOR  SYNECHIA  AND  PTEXYGIUM.      x    25. 
Narrow  peripheral  anterior  synechia  in  glaucoma  of  four  months'  duration.    The 
iris  is  commencing  to  degenerate.     See  also  Fig.  54. 


FIG.  205. — PERIPHERAL  ANTERIOR  SYNECHIA.      x    55. 

Old  glaucoma  ;  extensive  peripheral  anterior  synechia,  with  almost  complete 
atrophy  of  part  of  adherent  iris.  The  iris  elsewhere  is  degenerated  ;  note  hyaline 
degeneration  of  walls  of  vessels.  Schlemm's  canal  infiltrated. 


THE    IRIS   AND   ANTERIOR   CHAMBER  307 

leads  to  proliferation  of  the  endothelium  of  Descemet's  membrane  and 
of  the  iris,  with  fusion  of  the  two  layers.  The  endothelium  subsequently 
disappears  except  at  the  false  angle,  where  it  is  often  heaped  up.  There 
is  usually  round-celled  infiltration  of  the  deeper  layers  of  the  cornea 
and  sclera,  most  marked  around  the  canal  of  Schlemm,  which  may  be 
completely  masked.  The  fixed  tissue  cells  proliferate  later,  giving  rise 
to  young  connective-tissue  cells  and  fibres,  which  permanently  bind 
the  iris  firmly  to  the  corneo-sclera.  The  further  changes  which  ensue 
are  mostly  degenerative  in  character.  The  endothelium  of  the  liga- 
mentum  pectinatum  atrophies,  and  its  fibres  become  incorporated  in 
the  new  fibrous  tissue.  Organisation  also  occurs  around  Schlemm's 
canal,  which  becomes  partially  or  completely  obliterated.  The  iris 
stroma  atrophies  gradually,  being  represented  only  by  a  thin  layer  of 
fibrous  tissue  between  the  corneo-sclera  and  the  retinal  pigment 
epithelium,  which  itself  finally  becomes  thinned,  and  may  disappear  in 
parts.  The  pigment  often  migrates  into  the  neighbouring  tissues, 
being  especially  prone  to  follow  the  prevailing  lymph-stream,  so  that  it 
becomes  deposited  in  clumps  around  the  perforating  anterior  ciliary 
vessels.  Descemet's  membrane  also  atrophies,  but  often  extends  for  a 
short  distance  beyond  the  false  angle.  The  endothelium  here  and 
over  the  iris  may  gradually  secrete  a  new  hyaline  membrane  so  that 
Descemet's  membrane  appears  to  split  at  the  new  angle  (v.  p.  3°4)- 
Degenerative  changes  simultaneously  occur  in  the  whole  iris,  which 
assumes  all  the  characteristics  of  an  atrophic  iris. 

Obliteration  of  the  angle  may  be  partial  at  first,  so  that  the  whole 
circle  must  be  examined  before  the  full  extent  can  be  definitely 
demonstrated.  Other  pathological  changes  are  usually  present  where 
the  angle  is  open.  As  already  mentioned,  obliteration  may  occur  in 
the  absence  of  typical  iritis.  In  these  cases  proliferation  of  endothelium 
is  first  seen,  followed  by  formation  of  new  connective  tissue.  The 
latter,  as  it  contracts,  approximates  the  iris  to  the  corneo-sclera,  and 
leads  to  an  effectual  fusion  of  the  two.  This  process  has  been  com- 
pared by  Ziehe  and  Axenfeld  to  the  proliferation  of  the  endothelium  of 
lymphatics  in  chronic  hypersemia  with  increased  lymph-flow.  The  same 
process  occurs  at  the  edges  of  a  partial  obliteration  of  the  angle,  so 
that  there  is  a  continual  gradual  increase  in  extent,  and  ultimately 
the  whole  circle  is  completed.  Moreover,  the  local  peripheral 
anterior  synechia  doubtless  acts  as  an  irritant  to  the  iris,  causing 
deleterious  abnormal  stress  and  strain  during  the  perpetual  movements 
of  the  iris.  Hence  an  irritable  condition  is  induced,  which  is  easily  lit 
up  into  a  definite  iritis  by  slight  exciting  causes,  and  each  exacerbation 
increases  the  area  of  obliteration. 

The  efficiency  of  the  filtration  angle  is  impaired  by  many  conditions. 
and  several  of  these  manifest  themselves  anatomically  apart  from 
actual  peripheral  anterior  synechia.  It  is  well  known  that  in  irido- 
cyclitis  the  aqueous  contains  more  proteid  than  normal,  in  spite  of  the 
almost  complete  absence  in  some  cases  of  formed  elements,  such  as 
leucocytes,  etc.  This  condition  may  manifest  itself  in  ssctions  by  the 
presence  of  granular  deposits  in  the  anterior  chamber,  especially  at  the 
angle  and  on  the  bounding  surfaces.  In  most  cases  these  deposits  are 


THE    PATHOLOGY    OF   THE    EYE 


FIG.  206. — ANGLE  IN  PANOPHTHALMITIS.      x    10. 

Purulent  iritis  and  cyclitis.  The  iris  is  covered  with  a  fibrinous  coagulum 
containing  polymorphonuclear  leucocytes,  which  are  most  numerous  in  the  angle 
of  the  a.  c. 


FIG.  207. — PERFORATING  WOUND — PANOPHTHALMITIS.      x    7. 
The  cornea  is  densely  infiltrated  throughout  with  leucocytes;  the  a.  c.  is  full  of 
pus-cells  enmeshed  in  a  network  of  fibrin.     The  dark  mass  in  front  of  the  iris  on 
the  right  is  an  hyphsema.     The  iris,  lens,  and  ciliary  body  lie  in  a  bed  of   fibrin, 
leucocytes,  and  red  corpuscles. 


THE    IRIS   AND    ANTERIOR   CHAMBER 


309 


FIG.  208 — CHOLESTERIN  IN  ANTERIOR  CHAMBER,  x  55. 
Irido-cyclitis  following  injury  five  years  before  excision  ;  T  — .  A.  c.  full  of 
fibrinous  coagulum  containing  leucocytes,  pigment-cells,  free  pigment  granules, 
calcareous  granules,  and  cholesterin.  The  linear  white  spares  show  where  cholesterin 
crystals  have  been  dissolved  out.  Note  the  new  fibrous  tissue,  with  very  few  nuclei, 
on  the  surface  of  the  iris;  Descemet's  membrane  appears  to  split,  sending  a  hyaline 
membrane  on  to  the  surface  of  the  fibrous  lamina. 


FIG.  209. — PIGMENT  IN  ANGLE  CF  ANTERIOR  CHAMBER,      x    55 
Irido-cyclitis  following   a    blow.      The   angle    is    cpen,    but   the    ligamenturn 
pectinatum  is  covered  and  infiltrated  with  leucocytes  ar.d  pigment-cells;  most  ct 
the  latter  are  leucocytes  containing  pigment  granules. 


THE    PATHOLOGY   OF   THE   EYE 


FIG.  210.— PIGMENT  IN  ANGLE  OF  ANTERIOR  CHAMBER,      x    55. 
From  the  same  specimen  as  Figs.  173,  174.     The  ligamentum  pectinatum  iridis 
is  densely  packed  with  pigmented  cells,  and  there  are  great  clumps  of  pigment  in  the 
iris.     The  pigment  gave  the  reaction  for  iron. 


FIG.  211. — PIGMENT  IN  ANGLE  OF  ANTERIOR  CHAMBER,  x  55. 
The  angle  is  filled  with  a  dense  mass  cf  pigmented  retinal  epithelium,  with 
some  leucocytes  and  red  corpuscles.  The  iris  is  congested  and  necrotic,  as  shown 
by  the  absence  of  stained  nuclei.  There  is  a  similar  pigmented  mass  behind  the 
iris.  The  nature  of  the  case  is  doubtful;  there  had  been  an  injury  fourteen  days 
before  excision. 


THE    IRIS   AND   ANTERIOR   CHAMBER  311 

washed  out  during  the  processes  of  hardening  and  embedding.  When 
they  are  retained  they  may  show  slit-like  spaces  from  which  cholesterin 
crystals  have  been  dissolved  out,  a  condition  found  occasionally  in 
cases  of  phthisis  bulbi  (Fig.  208).  The  coagulum  is  often  fibrinous, 
and  may  be  found  filling  the  angle  and  covering  the  limiting  surfaces 
of  the  chamber,  or  even  filling  it  (Figs.  206,  207).  There  are  always 
cellular  elements — leucocytes,  red  corpuscles,  pigment-cells,  etc. — 
in  these  cases,  but  they  vary  greatly  in  number  and  variety. 

Leucocytes  are  often  carried  into  the  meshes  of  the  ligamentum 
pectinatum  by  the  lymph-stream.  Here  they  are  caught  as  in  a  filter, 
and  may  effectually  block  the  spaces  of  Fontana.  Schirmer  attributes 
rise  of  tension  in  sympathetic  ophthalmia  to  this  agency. 

Pigment-cells  and  clumps  may  also  be  caught  in  the  meshes  of  the 
ligamentum  pectinatum  (Lawford,  Priestley  Smith,  Panas  and  Rochon- 
Duvigneaud,  Dolganoff,  E.  v.  Hippel)  (Figs.  209,  210,  211).  The  pig- 
ment may  be  derived  from  the  iris,  ciliary  body,  or  retinal  pigment  epi- 
thelium, or  from  melanotic  growths  of  the  iris  (Solomon),  ciliary  bod) 
or  choroid  (Panas  and  Rochon-Duvigneaud),  or  from  blood-pigment. 
Haematogenous  pigment  gives  the  iron  reaction  in  the  early  stages ; 
moreover,  it  cannot  be  bleached  by  the  ordinary  methods  applicable  to 
autochthonous  pigment.  It  usually  occurs  as  granules  in  leucocytes. 
Other  forms  of  pigment  often  appear  as  dark  '"brown  homogeneous 
globules,  and  dense  aggregates  of  such  globules  are  sometimes  found 
in  the  angle. 

Red  corpuscles  are  frequently  found  in  small  numbers,  and,  of 
course,  in  large  numbers  in  cases  of  hyphaema  (Fig.  207). 

LEBER. — A.  f.  O.,  xix,  2,  1873.  KNIES. — A.  f.  O.,  xxii,  3,  1876;  xxiii,  2, 1877.  WEBER. 
— A.  f.  O.,  xxiii,  i,  1877.  ZIEHE  AND  AXENFELD. — Vossius'  Sammlung,  iv,  1901. 
SCHIRMER. — In  G.-S.,  1900.  PRIESTLEY  SMITH. — The  Pathology  and  Treatment  of 
Glaucoma,  London,  1891.  PANAS  AND  ROCHON-DUVIGNEAUD. — Recherches  anat.  et  clin. 
sur  le  Glaucome,  Paris.  1898.  LAWFORD. — R.  L.  O.  H.  Rep.,  xi,  3,  1887.  DOLGANOFF.— 
A.  f.  A.,  xxxix,  1899.  E.  v.  HIPPEL. — A.  f.  O.,  Hi,  3,  1901.  SOLOMON.— T.  O.  S.,  ii,  1882. 


CYSTS 

Cysts  of  the  iris  were  classified  by  Hulke  in  1867  into  four  groups — 

(1)  Delicate  membranous  cysts,  with  an  epithelial  lining  and  clear 
limpid  contents. 

(2)  Thick-walled  cysts,  with  opaque  thicker  contents. 

(3)  Solid  cystic  collections  of  epithelium,  wens  or  dermoid  cysts. 

(4)  Cysts  formed  by  deliquescence  in  myxomata. 

In  the  light  of  increased  knowledge  they  may  be  most  satisfactorily 
classified  into  the  following  groups  : 

(1)  Implantation    cysts,    including   pearl  cysts   and  atheromatous 
cysts  ; 

(2)  Retention  cysts ; 

(3)  Congenital  cysts ; 

(4)  Cysts  of  the  retinal  epithelium  ; 

(5)  Parasitic  cysts. 


312  THE    PATHOLOGY   OF   THE   EYE 

To  these  must  be  added  complex  cysts,  in  the  formation  of  which 
not  only  the  iris  but  also  the  cornea  and  anterior  chamber  take  part. 
These  are  usually  either  implantation  cysts  or  cysts  of  inflammatory 
origin.  Many  of  the  latter  are  not  true  cysts  in  the  strict  sense  of  the 
term. 

IMPLANTATION  CYSTS 

It  has  been  shown  in  the  case  of  the  skin  that  particles  of  the 
superficial  epidermis  can  be  transplanted  into  the  subcutaneous  tissue, 
and  will  often  grow  there,  forming  small  epithelial  tumours.  These 
have  been  called  epithelial  pearl  tumours  (Virchow),  cholesteatomata 
(Miiller),  or  epidermidomata.  They  occur  also  as  the  result  of  injury, 
e.  g.  pricks  with  a  needle,  or,  in  cattle,  prods  with  an  iron  spike 
(Bland-Sutton).  We  have  seen  that  they  also  occur  in  the  cornea 
as  the  result  of  injury  or  operation  (p.  253).  Sometimes  the  epithelium 
is  carried  deeper,  and  is  implanted  into  the  iris.  It  may  then 
grow  at  any  part,  but  most  frequently  near  the  periphery.  Not 
infrequently  eyelashes  are  carried  into  the  anterior  chamber ;  the 
epithelium  of  the  root-sheath  may  then  become  implanted  and  give 
rise  to  pearl  tumours  or  cysts  (Figs.  212,  213). 

The  possibility  of  these  implantations  has  been  proved  experi- 
mentally by  various  investigators.  Dooremaal  (1873)  introduced  inert 
foreign  bodies  and  living  tissue  into  the  iris  of  dogs  and  rabbits,  and 
succeeded  in  obtaining  grafts.  Goldzieher  (1874)  obtained  an  epithelial 
cyst  from  a  fragment  of  nasal  mucous  membrane.  Schweninger  (1875) 
implanted  hairs  into  the  anterior  chambers  of  dogs  and  rabbits. 
Masse  (1881)  most  exhaustively  investigated  the  subject.  The  graft 
undergoes  a  certain  amount  of  absorption  and  becomes  white ;  later 
it  may  become  vascularised.  Masse  kept  rabbits  for  eight  months 
with  such  grafts.  He  also  grafted  skin  containing  hairs.  Microsco- 
pically there  is  a  thick  layer  of  stratified  epithelium  formed,  united  by 
connective  tissue  to  the  iris.  He  saw  definite  cystic  development  in 
the  centre  of  such  a  graft,  derived  from  the  conjunctiva.  In  a  later 
communication  (1883)  he  showed  that  fragments  of  cornea  might  also 
be  implanted  and  give  rise  to  pearl  tumours.  Pieces  of  muscular 
tissue,  etc.,  are  absorbed,  and  do  not  give  rise  to  tumours.  Masse's 
experiments  were  repeated  and  confirmed  by  Hosch  (1885)  ;  he  showed 
that  sebaceous  glands  might  survive. 

Mackenzie  published  a  case  of  cyst  of  the  iris,  and  drew  attention  to 
its  traumatic  origin.  The  relationship  to  injury  was  particularly  noted 
by  Buhl  and  Rothmund,  with  whose  names  the  implantation  theory  is 
specially  associated.  Rothmund  (1871)  collected  thirty-six  cases,  in 
which  twenty-eight  had  a  perforating  wound;  in  three  there  were  eye- 
lashes in  the  anterior  chamber ;  in  two  cysts  followed  cataract  opera- 
tions. Monoyer  (1872)  distinguished  between  the  solid  pearl  tumours 
and  the  cysts,  and  threw  doubt  upon  the  traumatic  origin.  In  one  case 
there  were  two  pearl  tumours,  the  size  of  a  millet-seed,  resembling 
mother-of-pearl.  Histologically  they  were  composed  of  solid  con- 
centric lamellae  of  epithelium,  arranged  like  the  layers  of  an  onion.  The 


THE    IRIS   AND   ANTERIOR   CHAMBER  313 

central  part  is  often  horny  in  these  growths.     Becker  reported  a  cyst 
with   compact  walls,  containing   many  elastic  fibres,  and  lined  with 


^-r>-:-^?'-  •'-•''--••  S^N. 


FIG.  212. — CYST  OF  IRIS,      x    10. 

From  Treacher  Collins.     Following  implantation  of  an  eyelash,     a  is  the  part 
shown  in  Fig.  213.     (T.  O.  S.,  xiii.) 

flattened   epithelium.     Stolting   described    two    epithelial   cysts,   and 
pointed  out  the  possibility  of  continuity  of  the  epithelium  with  that  of 


FIG.  213. — CYST  OF  IRIS,      x   300. 

From   Treacher  Collins.     A,   contents   of  cyst;    B,  epithelial  lining   of  cyst; 
C,  iris  ;  D,  lens  capsule  ;  E,  lens.     (T.  O.  S.,  xiii  J 

the   surface   by   downgrowth  along  the   lips   of  the  wound   into  the 
anterior  chamber. 


314 


THE    PATHOLOGY   OF   THE   EYE 


FIG.  214. — EPITHELIAL  CYST  OF  THE  ANTERIOR  CHAMBER,  x  5. 
From  a  man,  xt.  56,  who  had  had  a  wound  of  the  cornea,  with  prolapsed  iris, 
two  and  a  half  years  before.  The  cyst,  7  mm.  in  diameter,  was  situated  below  the 
cornea.  It  is  lined  with  epithelium  varying  in  the  number  of  layers.  The  epithelium 
is  continuous  over  the  iris,  fibrous  tissue  filling  the  coloboma,  etc.,  and  lines  the 
whole  anterior  chamber. 


FIG.  215. — EPITHELIUM  COVERING  IRIS,      x    130. 

Four  months  after  iridectomy  ;  T  +  2  before  excision.  The  iris  is  covered  by 
a  layer  of  stratified  epithelium  which  is  continued  across  the  coloboma,  shutting  off 
the  posterior  from  the  anterior  chamber.  There  was  no  epithelium  on  the  back  of 
the  cornea.  The  number  of  layers  of  cells  varies,  in  places  there  are  small  cysts ; 
the  epithelium  resembles  conjunctival  epithelium.  The  figure  shows  the  sphincter 
iridis  cut  obliquely. 


THE    IRIS   AND    ANTERIOR   CHAMBER 


315 


\Vintersteiner  records  a  small  pearl  tumour  growing  on  the  iris  in  the 
angle  of  the  anterior  chamber.  It  consisted  chiefly  of  very  fine,  wavy 
lamellae,  without  nuclei,  and  embedded  in  granulation  tissue  and  new- 
formed  fibrous  tissue.  The  lamellae  were  horny  epithelial  cells.  These 


FIG.  216.— CYST  OF  EVE.  pIG    217.— CYST  OF  EYE. 

From  Treacher  Collins.     Large  epithelial  From  Treacher  Collins.    Showing  lamin- 

cyst  in  a   shrunken  eye.     (T.    O.    S.,  xi.)         ated  epithelium  lining  the  cyst  in  Fig.  216 

(T.  O.  S.,  xi.) 

acted  as  foreign  bodies  and  caused  the  formation  of  many  giant-cells. 
The  whole  was  pervaded  with  chloresterin  crystals. 

Cases  of  eyelashes  growing  in  the  iris  and  anterior  chamber  have 
been  recorded  by  Rockliffe,  Stoeber,  Pamard,  Schweigger,  and  Cross 
and  Collins,  and  others.  In  the  last-mentioned  case  (Figs.  212,  213), 
the  cyst  in  the  iris  had  opaque  white  contents,  consisting  of  polyhedral 
cells,  most  without  nucleus.  They  were  probably  epithelial  cells  under- 
going degeneration.  There  were  numerous  globules  of  fat  and  probably 
cholesterin.  The  cyst  was  lined  with  epithelium.  This  case  represents 
a  transition  stage  from  the  solid  pearl  tumour  to  the  fully  developed  cyst. 


FIG.  218. — CYST  OF  ANTERIOR  CHAMBER. 
From    Treacher    Collins.       Following 
cataract  extraction.     (T.  O.  S.,  xii.) 


FIG.  219. — CYST  OF  ANTERIOR  CHAMBER. 
From  Treacher  Collins.     Epithelium  lining 
cyst  shown  in  Fig.  218.     (T.  O.  S.,  xii.) 


Implantation  cysts  sometimes  contain  sebaceous  material  as  well  as 
hairs,  as  in  v.  Graefe's  case.  One  recorded  by  Strawbridge  was  lined 
with  a  layer  of  squamous  epithelial  cells,  swollen,  and  in  an  advanced 
stage  of  fatty  degeneration.  These  cells  were  free  from  each  other,  and 
were  surrounded  by  granular  matter,  fat,  and  cholesterin  crystals.  In 


316  THE    PATHOLOGY   OF   THE    EYE 

Snail's  case  the  contents  of  the  cyst  consisted  of  a  number  of  very 
large,  clear,  closely  packed  cells  like  fat-cells,  in  which  no  nucleus 
was  discernible  ;  of  cholesterin  crystals  in  great  numbers ;  of  a  large 
quantity  of  fatty  matter,  both  in  the  purely  granular  and  oily  forms ; 
of  pigment-cells  and  granules  in  small  quantity ;  of  sparsely  scattered 
tesselated  epithelium,  and  of  a  purely  granular  material. 

More  commonly  the  contents  of  the  cysts  are  serous  or  slightly 
turbid  fluid.  Cases  <<f  this  kind  have  been  reported  by  Benson, 
Morton,  Marshall,  and  others.  In  these  the  iris  is  often  split  jnto  two 
layers  ;  the  anterior  is  often  adherent  to  the  back  of  the  cornea,  and  is 
usually  thin  and  atrophic.  The  posterior  layer  constitutes  the  greater 
part  of  the  iris,  and  forms  the  posterior  wall  of  the  cyst,  which  is,  as 


FIG.  220. — EPITHELIAL  CYST  OF  POSTERIOR  CHAMBER,      x    12. 
The  iris  is  adherent  to  the  cornea.     The  space  bounded  by  iris,  ciliary  pro- 
cesses, and  lens  is  lined  by  stratified  epithelium. 

usual,  lined  with  irregular  and  often  ill-developed  stratified  epithelium. 
This,  where  best  developed,  sometimes  closely  resembles  the  corneal  or 
conjunctival  epithelium,  the  cubical  cells  covering  the  iris,  and  the  flat- 
tened cells  lining  the  cavity. 

Implantation  cysts  are  often  not  limited  to  the  iris,  this  forming 
only  the  posterior  wall  (Figs.  214,  216,  218).  The  anterior  wall  is 
then  formed  by  the  back  of  the  cornea,  an  anterior  synechia  closing 
the  cyst,  which  is,  as  usual,  lined  with  epithelium.  Sometimes  the 
cyst  extends  on  to  the  capsule  of  the  lens,  which  forms  part  of  the 
posterior  wall,  and  it  may  even  protrude  under  the  conjunctiva,  as  in 
a  case  reported  by  Critchett.  Often  several  epithelial  cysts  occur  in 
the  same  eye,  of  various  sizes,  some  being  purely  corneal  or  iridic,  and 
others  bounded  by  various  portions  of  the  walls  of  the  anterior  chamber. 


THE    IRIS   AND    ANTERIOR   CHAMBER  317 

Wintersteiner  records  a  case  in  which   the  epithelium    invaded    the 
wounded  lens  and  formed  numerous  folds  in  it. 

The  occurrence  of  dovvngrowths  of  the  superficial  epithelium  into 
the  anterior  chamber,  which  may  result  in  the  whole  or  parts  of  the 
chamber  being  lined  by  stratified  epithelium,  must  be  remembered. 
Doubtless  many  so-called  implantation  cysts — more  especially  of  the 
iris  and  anterior  chamber — are  due  to  this  cause,  as  rightly  insisted  on 
by  Stolting  (v.  p.  165). 

HULKE. — R.  L.  O.  H.  Rep.,  vi,  i,  1869.  BLAND-SUTTOX. — Hunterian  Lectures, 
R.C.S.,  1889;  Tumours,  London,  1896.  DOOREMAAL. — A.  f.  O.,  xix,  3,  1873.  GOLDZIEHER. 
— Arch.  f.  exp.  Path.  u.  Pharm.,  ii.  SCHWENINGER. — Z.  f.  Biologic,  xi,'  1875.  "MASSE. 
— Comptes  rendus  de  1'Acad.  des  Sciences,  1881,  1883;  Kystes,  Tumeurs  perles  et  Tumeurs 
dermoides  de  1'Iris,  Paris,  1885.  HOSCH. — Virchow's  Archiv,  xcix,  1885.  MACKENZIE. — 
Diseases  of  the  Eye,  London,  1830.  ROTHMUND. — B.  d.  o.  G.,  1871;  K.  M.  f.  A.,  x,  1872. 
MOXOYER. — Ann.  d'Oc.,  Ixvii,  1872.  BECKER. — B.  d.  o.  G.,  1871.  STOLTING. — A.  f.  O., 
xxxi,  3,  1885.  WINTERSTEIXER. — B.  d.  o.  G.,  igoo.  TREACHER  COLLINS. — T.  O.  S.,  xi' 
1891.  *CROSS  AND  TREACHER  COLLINS. — T.  O.  S.,  xii,  1892;  xiii,  1893.  STRAWBRIDGE  — 
T.  Amer.  O.  S.,  1878.  SXELL.— R.  L.  O.  H.  Rep.,  x,  1881.  MORTON.— T.  O.  S.,  xiii,  1893. 
HAXSELL. — T.  Am.  O.  S.,  1895.  DEVEREUX  MARSHALL. — T.  O.  S.,  xix,  1899.  "LAGSANGE. 
— Tumeurs  de  1'CEil,  i,  Paris,  1901. 


RETENTION  CYSTS 

Serous  cysts  occur  in  the  iris,  which  are  not  lined  by  epithelium, 
and  in  which  no  history  of  injury  can  be  obtained.  Some  of  these 
are  congenital  (v.  infra),  others  develop  spontaneously.  They  are 
probably  due  to  blocking  of  the  mouths  of  the  crypts,  which  become 
distended  by  the  retained  lymph. 

Sattler  considered  it  absolutely  necessary  that  some  foreign  body, 
no  matter  how  microscopic,  should  be  incorporated  in  the  iris  in  order 
to  produce  irritation,  leading  to  increased 'exudation  (exudation  cysts). 
Schmidt-Rimpler  advanced  the  view  that  the  cysts  were  due  to 
thickening  and  fusion  of  the  strands  which  are  often  seen  crossing 
the  crypts,  de  Wecker  considered  that  they  were  caused  by  adhesion' 
and  fusion  of  folds  of  the  iris,  with  enclosure  of  aqueous  fluid  ;  this 
view  almost  demands  previous  injury,  and  does  not  satisfactorily 
explain  the  so-called  idiopathic  cysts.*  Eversbusch  considered  them 
due  to  detachment  of  the  ligamentum  pectinatum  iridis,  caused  by 
injury  and  haemorrhage.  The  anterior  and  middle  layers  of  the  iris 
are  also  torn  up,  transudation  occurs  from .  the  circulus  arteriosus 
iridis  major,  and  a  cyst  is  formed  in  the  space  between  the  iris  and 
cornea.  Gayet  published  a  case,  examined  microscopically,  which 
supports  Eversbusch's  theory. 

Treacher  Collins  has  reported  two  cases  which  he  regards  as  sup- 
porting Schmidt-Rimpler's  theory.  There  was  no  history  of  injury. 
In  one,  which  may  be  considered  a  typical  case,  the  cyst  was  situated 
nearer  the  anterior  than  the  posterior  surface  of  the  iris.  It  was  lined 
with  a  layer  of  flattened  endothelial  cells,  resting  on  a  very  distinct 
basement  membrane.  The  latter  was  best  seen  op,  the  posterior  wall, 
and  was  composed  of  closely  packed  nucleated  fibres. 

Greeff  has   insisted   upon   the   fact  that  retention  cysts  lined  by 


318  THE    PATHOLOGY    OF   THE    EYE 

endothelium  can  occur  after  injury  as  well  as  implantation  cysts. 
There  can  be  no  doubt  that  endothelium,  e.  g.  that  lining  Descemet's 
membrane,  can  at  times  give  rise  to  several  layers  of  superposed  cells, 
quite  apart  from  the  frequent  appearance  of  several  layers  due  to  oblique 
section.  It  is  by  no  means  easy  always  to  determine  whether  the  cells 
are  of  epi-  or  endo-thelial  origin,  especially  when  one  remembers  that  epi- 
thelium growing  under  these  abnormal  circumstances  is  often  atypical. 
The  retention  cysts  are  said  to  be  always  unilocular.  They  are 
often  collapsed  and  folded  when  cut,  so  that  appearances  of  multiio- 
cular  cysts  are  common  in  sections. 

SATTLER. — K.  M.  f.  A.,  xii,  1874.  SCHMIDT-RIMPLER. — A.  f.  O.,  xxxv,  i,  1885.  DE 
WECKER. — Traite  d'O.,  ii,  1886.  EVERSBUSCH. — Beitrage  z.  Genese  der  Iriscysten,  1880. 
*TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xiii,  i,  1890.  GREEFF. — A.  f.  A.,  xxv,  1892. 
*LAGRANGE. — Tumeurs  de  1'CEil,  i,  Paris,  1901. 

CONGENITAL  CYSTS 

A  few  cases  of  true  dermoid  cysts  of  the  iris  have  been  reported 
(v.  Rosenzweig,  Lagrange).  They  are  practically  identical  microscopi- 
cally with  the  pearl  tumours  or  the  implantation  cysts,  and  it  is  doubtful 
in  which  category  they  should  be  included,  v.  Rosenzweig,  indeed,  is 
inclined  to  put  the  implantation  cysts  amongst  the  true  dermoids. 
This  is  certainly  wrong  in  most  cases,  the  epithelium  having  but 
slight  resemblance  to  epidermis,  owing  to  the  absence  of  prickle-cells. 

Many  of  the  retention  cysts  are  congenital.  One  recorded  by  Clark 
probably  originated  in  the  spaces  of  Fontana.  Guaita  explains  another 
on  Eversbusch's  theory.  Both  were  lined  with  endothelium.  Others 
by  Herrnheiser,  Klein,  Noyes,  etc.,  are  insufficiently  reported. 

A  remarkable  congenital  cyst,  lined  by  ciliated  epithelium,  has  been 
published  by  O.  Becker  and  Kriickow.  The  cyst  lay  in  an  anterior 
staphyloma. 

Congenital  cysts  occur  in  connection  with  colobomata  of  the  iris, 
etc.,  and  other  malformations  of  the  eye.  These  will  be  considered 
elsewhere.  It  is  possible  that  Becker  and  Kruckow's  case  belongs  to 
this  group. 

v.  ROSENZWEIG. — B.  f.  A.,  xvi,  1894.  *LAGRAXGE. — Tumeurs  de  1'CEil,  i,  Paris,  1901. 
CLARK. — VIII  Internal.  Congress,  Edinburgh,  1894.  GUAITA. — Ann.  di  Ott.,  x,  1881. 
OSBORN. — St.  Thomas's  Hosp.  Rep.,  vi.  O.  BECKER. — Atlas,  Wien.,  1878.  KRUCKOW. — 
A.  f.  O.,  xxi,  2,  1875. 

CYSTS  OF  THE  RETINAL  EPITHELIUM 

Treacher  Collins  has  shown  that  cysts  may  be  formed  by  separation 
-of  the  two  layers  of  retinal  pigmented  epithelium  at  the  back  of  the 
iris  (Figs.  221 — 3).  Small  cystic  spaces  of  this  nature  are  of  frequent 
occurrence  in  various  pathological  conditions.  Treacher  Collins 
records  three  cases.  In  one,  in  a  man  set.  64,  a  black  mass  with  a 
notch  in  the  middle,  projected  from  behind  the  lower  margin  of  the 
pupil.  In  another,  a  boy  set.  10,  the  eye  had  been  wounded  with  a 
pair  of  scissors  seven  years  before  ;  the  posterior  wall  of  the  cyst  was 


THE    IRIS   AND   ANTERIOR   CHAMBER 

adherent  to  a  cyclitic  mass  of  fibrous  tissue  and  to  the  capsule  of  the 
shrunken  lens.  In  the  third  there  was  no  posterior  synechia  ;  there 
was  a  sarcoma  of  the  ciliary  body — "  the  pressure  of  this  tumour  on 
the  base  of  the  iris  gave  rise  not  only  to  oedema  of  its  stroma,  which  is 


FIG.  221. — CYST  OF  RETINAL  PIGMENT  EPITHELIUM. 
From  Treacher  Collins. 

seen  to  be  swollen,  but  also  to  effusion  of  fluid  between  its  two  uveai 
layers,"  and  so  to  the  formation  of  a  small  cyst  not  far  from  the  pupillary 
border  (Fig.  222).  Eales  and  Sinclair  record  two  such  cysts  in  a 
glaucomatous  eye. 

These  cysts  are  doubtless  due,  as  suggested  by  Treacher  Collins,  to 
interference  with  the  lymph-flow  in  the  iris.  This  will  be  aided,  if  not 
caused,  by  adhesion  of  the  root  of  the  iris  to  the  back  of  the  cornea, 
and  will  be  further  increased  by  fusion  of  the  posterior  wall  with 
cyclitic  deposits  (partial  or  total  posterior  synechia)  (Fig.  223).  The 


FIG.  222. — CYST  OF  RETINAL  PIGMENT  EPITHELIUM. 

After  Treacher  Collins.  Small  cyst  between  the  two  layers  of  pigment 
epithelium  ;  from  an  eye  containing  a  melanotic  sarcoma  of  the  ciliary  body.  The 
iris  was  swollen  and  cedematous. 

accumulation  of  fluid  is  sometimes  considerable,  the  anterior  wall,  with 
the  main  part  of  the  atrophic  iris,  being  bulged  forwards.  This  is  one 
cause  of  what  may  be  regarded  clinically  as  a  partial  bombe  iris. 

An  extreme  condition  of  oedema  of  the  pigment  layer,  with  the 
formation  of  numerous    small   cystic   spaces,  is  common  in  diabetes. 


320 


THE    PATHOLOGY    OF   THE   EYE 


Hirschberg  and  Snellen  first  pointed  out  that  in  iridectomy  in  diabetics 
the  pigment  is  set  free  in  the  aqueous,  which  becomes  dark  and  cloudy. 
Microscopically  Kamocki  found  enormous  swelling  and  sponginess  of 
the  uveal  layer,  which  is  from  0*17 — 0^33  mm.  thick.  Instead  of 
forming  two  layers  there  are  many  layers  of  cells,  which  are  extremely 
vacuolated,  the  pigment  with  the  nucleus  being  pressed  to  one  side  of 
the  cell.  The  cells  do  not  stain  with  most  dyes,  but  a  few  stain  with 
haematoxylin,  and  then  show  a  fine  network  of  protoplasm.  The 
posterior  cells  are  much  elongated  cylinders,  the  anterior  cubical  or 
flat.  The  latter  are  particularly  swollen  and  depigmented.  The 
breaking  down  and  fusion  of  the  cells  leads  to  the  formation  of  cysts 


FIG.  223. — CYSTS  OF  THE  PARS  RETINALIS  IRIDIS.      x    7. 
From  a  boy,  five  years  after  injury.     Seclusio  and  occlusio  pupillae  ;  separation 
of  the  two  layers  of  retinal  pigment  epithelium,  with  the  formation  of  numerous 
cysts.     The  pupillary  membrane  is  extremely  delicate.     Note  the  anterior  capsular 
cataract  and  detached  retina. 

reaching  a  breadth  of  1*5  mm.  and  a  height  of  o'8  mm. ;  they  contain 
free  nuclei,  pigment  granules,  and  fine,  pale  globules.  The  early  stages 
were  seen  by  O.  Becker  in  cases  of  diabetic  cataract ;  and  the  pro- 
liferation, vacuolation,  and  sponginess  were  also  described  by  Deutsch- 
mann.  The  remainder  of  the  iris  is  usually  normal,  but  may  show 
cedema  (Becker)  or  atrophy  (Deutschmann).  Kako  has  recently  con- 
firmed the  observations  upon  the  retinal  pigment  layer.  The  condition 
is  occasionally  seen  in  other  degenerative  conditions,  but  is  markedly 
influenced  by  the  presence  of  sugar  in  the  aqueous,  etc. 

TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xiii,  i,  1890;  Researches,  London,  1896. 
EALES  AND  SINCLAIR. — T.  O.  S.,  xvi,  1896.  ZIMMERMANN. — Ann.  of  Ophth.,  1897. 
KAMOCKI. — A.  f.  A.,  xvii,  1887  ;  xxv,  1892.  BECKER. — Zur  Anat.  der  gesunden  u.  kranken 
Linse,  Wiesbaden,  1883.  DEUTSCHMANN. — A.  f.  O.,  xxxiii,  2,  1887.  KAKO. — K.  M.  f.  A., 
xli,  1903. 


THE    IRIS   AND    ANTERIOR   CHAMBER  321 

PARASITIC  CYSTS 

The  first  recorded  case  of  cysticercus  in  the  eye  was  in  the  anterior 
chamber  (Schott  and  Scemmering,  1829).  Others  in  this  situation  have 
been  recorded  by  v.  Graefe  (1853),  Hirschler  (1861),  Windsor  (1862), 
Teale  (1866),  and  others.  They  are  extremely  rare  here  (two  in  60,000 
cases,  A.  Graefe  ;  one  in  30,000,  Forster) ;  and  in  no  case  have  they  been 
multiple.  In  Kriiger's  case  the  cyst  was  grey  and  transparent,  2  mm. 
in  diameter,  implanted  in  the  lower  part  of  the  iris  by  a  short,  very 
thin  pedicle.  It  altered  in  shape  from  time  to  time,  often  rapidly.  The 
protrusion  of  the  head  of  the  scolex  can  often  be  seen  very  well  in  this 
situation.  Its  presence  leads  to  severe  plastic  iritis. 

SCHOTT  AND  SCEMMERING;  v.  GRAEFE. — In  SICHEL,  Iconographie  ophth.,  Paris,  1852. 
HIRSCHLER. — A.  f.  O.,  iv,  2,  1858.  WINDSOR. — R.  L.  O.  H.  Rep.,  iii,  3,  1862.  TEALE.— 
R.  L.  O.  H.  Rep.,  v,  1866.  KRUGER.— K.  M.  f.  A.,  v,  1867.  KRIKS.— A.  f.  O.,xxiv,  i,  1878. 
TREITEL. — A.  f.  A.,  xv,  1885.  GROSSMANN. — Ophth.  Rev.,  vii,  1888.  HERRNHEISER. — 
Prag.  med.  Woch.,  1889.  PRAGER. — Wien.  klin.  Woch.,  1892. 

FilaricB  have  very  occasionally  been  observed  in  the  anterior 
chamber.  They  do  not  form  cysts,  but  may  be  conveniently  referred 
to  here.  The  species  has  not  been  determined.  Mercier  (1771)  recorded 
the  first  case  in  a  negress  of  San  Domingo ;  the  cases  reported  by 
Macnamara,  Barkan,  and  Drake-Brockman  are  doubtful.  The  most 
complete  observation  is  by  Coppez  and  Lacompte,  in  a  negress, 
aet.  2 1,  from  the  Congo.  The  movements  of  the  worm  produced  no 
inflammatory  reaction,  but  iritis  set  in  the  day  after  it  died.  It  was 
then  removed  and  found  to  be  15*2  mm.  long,  incompletely  developed, 
and  undifferentiated  as  to  sex. 

MACNAMARA. — Indian  Annals  of  Med.  Sc.,  viii,  1864.  BARKAN.— A.  of  O.,  v,  1876; 
A.  f.  A.,  v,  1876.  *COPPEZ. — A.  d'O.,  xiv,  1894.  *LACOMPTE. — Ann.  de  la  Soc.  de  Med. 
de  Gand,  1894.  DRAKE-BROCKMAN. — Ophth.  Rev.,  1894.  GAUTHIER. — Ann.  d'Oc.,  cxiv, 
1895.  KRAEMER. — In  G.-S.,  x,  1899. 


COMPLEX  CYSTS 

We  have  already  referred  to  complex  epithelial  cysts,  which  involve 
not  only  the  iris  but  also  neighbouring  parts.  More  common  are  cystic 
spaces  formed  by  shutting  off  portions  of  the  anterior  chamber,  as  the 
result  of  inflammatory  adhesions  of  the  iris  to  the  cornea,  etc.  Such 
cases  were  early  recorded  by  de  Wecker,  Knapp,  Alt,  and  others.  The 
formation  of  a  horseshoe-shaped  posterior  synechia  and  subsequent  de- 
velopment of  a  localised  condition  of  bombe  iris  gives  rise  to  a  condition 
often  indistinguishable  from  a  cyst  of  the  iris.  Such  a  case,  as  the 
result  of  an  intra-ocular  foreign  body,  is  recorded  by  Treacher  Collins. 
The  anterior  wall  was  formed  by  the  upper  part  of  the  iris,  bowed 
forwards  like  a  sail ;  the  posterior  by  the  lens  capsule.  Inflammatory 
tissue  united  the  pupillary  margin  of  the  iris  to  the  lens  capsule 
internally,  and  the  anterior  of  the  ciliary  processes  to  the  lens  capsule 
externally.  In  Alt's  case  the  iris  was  adherent  to  the  cornea  except  at 
the  centre,  where  it  passed  back  and  formed  a  posterior  synechia  with 

21 


322  THE    PATHOLOGY    OF   THE   EYE 

the  lens  capsule.     The  central  space  was  surrounded  by  inflammatory 
tissue,  lined  with  endothelium. 

Appearances  resembling  these  cysts  are  often  seen  in  sections,  but 
the  cavity  is  rarely  completely  shut  off  from  the  rest  of  the  anterior 
chamber.  Only  serial  sections  could  conclusively  demonstrate  this, 
and,  as  far  as  I  am  aware,  no  case  has  ever  been  submitted  to  this 
crucial  test. 

DE  WECKER. — Traite  d'O.,  ii,  1886;  A.  f.  A.,  i,  1869.  KNAPP. — A.  of  O.  and  Otology, 
i,  1869.  ALT.  —  Lectures  on  the  Human  Eye,  New  York,  1880. 


TUMOURS    OF   THE    IRIS 

N^EVUS,  MELANOMA 

Congenital  pigmented  spots  in  the  iris  are  not  very  uncommon. 
They  occur  in  two  forms — as  raised  spots,  pigmented  ncevi,  or  as  small 
circumscribed  tumours,  melanomata.  v.  Graefe  described  a  case  of  the 
latter,  but  without  histological  examination.  Knapp  found  such  a 
growth  to  consist  of  a  circumscribed  development  of  branching  and 
anastomosing  stroma-cells,  some  of  which  were  unpigmented,  but  most 
were  pigmented.  There  was  no  sharp  delimitation  from  the  sur- 
rounding normal  tissues. 

Fuchs  found  that  pigmented  nsevi  usually  lay  in  the  anterior  limit- 
ing layer  of  the  iris.  Here  the  pigment  granules  may  be  so  densely 
aggregated  that  the  nuclei  of  the  cells  are  hidden  ;  the  individual  pig- 
ment granules  are  often  very  large.  The  surface  of  the  iris  may  project 
forwards  at  the  site  of  the  nsevus,  which  frequently  lies  upon  a  bed  of 
pigmented  stroma-cells.  The  naevi  are  often  situated  near  the  pupillary 
edge  of  the  iris.  Fuchs  in  his  first  paper  evidently  regarded  the  cells 
as  derived  from  the  stroma,  though  he  here  too  recognises  the  existence 
of  pigmented  spots  derived  from  the  retinal  pigment  epithelium. 

The  pigmented  cells  of  the  naevus  may  be  round  (Baas),  in  which 
case  their  resemblance  to  those  of  true  nsevus  of  the  skin,  conjunctiva, 
etc.,  is  well  marked.  It  is  by  no  means  certain,  however,  that  true 
naevus  occurs  in  this  situation.  As  shown  elsewhere  (p.  129),  there  is  a 
growing  tendency  to  regard  dermal  naevus  as  a  modified  epithelial 
deposit.  There  is  normally  no  epithelium  near  the  surface  of  the  iris  ; 
this  does  not,  however,  eliminate  the  possibility  of  an  epithelial  "  rest," 
nor  does  it  militate  against  the  endothelial  theory  of  congenital  nasvi. 
With  the  scanty  material  at  one's  disposal  it  would  be  unwise  to 
express  a  dogmatic  opinion  as  to  these  deposits.  What  may  be  stated 
with  certainty  is,  that  two  types  of  pigmented  spots  are  met  with  in  the 
iris  :  (i)  aggregations  of  branched  pigmented  stroma-cells  ;  (2)  aggre- 
gations of  pigmented  cells  derived  from  the  retinal  pigment  epithelium. 
Knapp's  case  is  an  example  of  the  first  type,  Fuchs's  of  the  second,  as  he 
has  since  admitted  (Anargyros). 

Nsevi  may  give  rise  to  definite  tumours,  which  are  usually  relatively 
benign,  but  may  be  malignant.  Much  confusion  not  only  in  nomen- 


FIG.  224. — MELANOMA  OF  IRIS. 
After  Treacher  Collins,  R.  L.  O.  H.  Rep.,    xii. 
From  a  man  act.  21  ;  there  was  a  dark  spot  down 
and  out  more  than  four  years  previously. 


FIG.  225. — MELANOMA  OF  IRIS. 
After  Treacher  Collins.     From  the  same  case  as 
Fig.  224,  showing  section  of  lower  part  of  iris  under 
a  high  power. 


' 


i«s 


,-.v;-> 


*^rx": 


FIG.  227. — MELANOMA  OK  IRIS. 

After  Anargyros,  A.  f.  A.,  xlvi. 
Showing  clearly  the  relationship  of 
the  pigmented  cells  to  the  retinal 
epithelium. 


FIG.  226. — HORSE'S  IRIS. 

After  Treacher  Collins.     Showing  the  mass  of  pig- 
mented epithelium  at  the  pupillary  border. 


324  THE    PATHOLOGY   OF   THE    EYE 

clature,  but  also  as  to  the  real  character  of  these  growths  has  arisen. 
They  are  often  classified  amongst  the  sarcomata,  and  this  is  especially 
the  case  with  the  more  malignant  types.  Those  who  recognise  their 
origin  from  congenital  nasvi  classify  them  as  sarcomata  or  as  carcino- 
mata  according  to  their  predilection  for  one  or  other  view  of  the 
nature  of  the  naevus-cell.  Others  give  them  a  separate  designation, 
melanomata,  and  this  term  is  often  restricted  to  the  more  benign  type. 
Fuchs  divides  the  benign  tumours  or  melanomata  into  two  classes  : 
(i)  those  which  are  due  to  proliferation  of  the  pigmented  stroma-cells 
of  the  iris  ;  (2)  those  which  occur  at  the  pupillary  margin  of  the  iris, 
and  are  developed  from  the  retinal  epithelial  cells.  The  first  class  often 
reach  a  certain  size  —  usually  quite  small  —  and  remain  for  many  years 


i56&«$¥*&&  r'&'^rM 

™s^& Vfiv^  >'<€)-      V.V^  v | « v 


FIG.  228. — MELANOMA  OF  IRIS,      x    300. 
Treacher  Collins,  T.  O.  S.,  xix. 

unchanged.  They  are  liable  at  any  time  to  take  on  malignant  growth, 
and  it  can  scarcely  be  doubted  that  the  resultant  tumours  are  rightly 
designated  sarcomata.  The  second  class  resemble  the  normal  out- 
growths found  at  the  pupillary  margin  in  horses  and  many  lower 
mammals  (Fig.  226).  These  have  been  precisely  investigated  by  Trea- 
cher Collins,  Alt,  Bayer,1  and  consist  of  masses  of  the  pigmented 
retinal  epithelium  into  which  a  few  blood-vessels  and  a  small  amount  of 
connective  tissue,  derived  from  the  iris  stroma,  have  penetrated. 

Anargyros  has  recently  given  the  best  description  of  melanomata  of 
the  iris,  and  this  shows  that  they  are  by  no  means  limited  to  the  pupil- 

1  TREACHER  COLLINS. — Researches  into  the  Anatomy  and  Pathology  of  the  Eye, 
London,  1896.  ALT. — Amer.  Jl.  of  Ophth.,  xv,  1898.  BAYER. — Handbuch  d.  thierarztl. 
Chirurgie,  v. 


THE    IRIS   AND    ANTERIOR   CHAMBER  325 

lary  margin.  There  were  two  small  tumours  in  the  upper  part  and  one 
large  one  (i  mm.  broad  by  2\  mm.  long)  in  the  lower  part  of  the  pupil, 
besides  several  nsevi  scattered  in  other  parts  of  the  iris.  The  growths 
consisted  of  masses  of  deeply  pigmented  cells  formed  by  proliferation 
of  the  retinal  epithelium  into  the  stroma  of  the  iris  (Fig.  227).  They 
were  situated,  therefore,  for  the  most  part  in  the  posterior  layers.  The 
individual  cells  were  irregular  in  shape,  and  filled  with  very  fine,  round, 
brown  pigment  granules,  which  hid  the  nuclei  from  view.  Similar  out- 
lying cells  were  scattered  through  the  iris  stroma.  The  tumour-cells 
were  continuous  with  the  retinal  epithelium,  so  that  the  so-called 
Bruch's  membrane  ran  directly  into  the  growths. 

The  favourite  place  for  melanomata  is  undoubtedly  the  pupillary 
margin,  and  this  is  explained  by  the  meeting  of  the  two  layers  of  the 
secondary  optic  vesicle  at  this  spot.  Such  places  are  always  more  sub- 
ject than  others  to  congenital  malformations.  The  next  commonest 
site  is  the  neighbourhood  of  the  peripheral  edge  of  the  sphincter,  where 
ingrowths  of  the  retinal  pigment  are  not  infrequent  in  normal  eyes. 
The  growths  may  lie  at  the  extreme  periphery  of  the  iris,  in  such  a 
position  as  to  be  invisible  clinically  (Anargyros). 

Treacher  Collins  described  a  pigmented  growth  of  the  iris  in  a 
woman  of  sixty-three,  which  he  regarded  as  a  "pigment  mole  rather 
than  a  melanotic  sarcoma."  There  seems  no  doubt  that  it  had  existed 
since  childhood.  It  was  composed  of  large  endothelium-like  cells,  with 
oval,  very  sharply  defined  nuclei  (Fig.  228).  The  cells  were  contained 
in  a  delicate  mesh  of  connective  tissue.  Much  pigment  was  scattered 
irregularly  throughout  the  growth,  being  quite  dense  in  parts  and  absent 
in  other  parts.  Griffith  regarded  it  as  a  large  round-celled  sarcoma. 

v.  GKAEFE. — A.  f.  O.,  vii,  2,  1860.  KNAPP. — Intra-ocular  Tumours,  New  York,  1869. 
FUCHS. — A.  f.  A.,  xi,  1882  ;  A.  f.  O.,  xxxi,  3,  1885 ;  Text-book.  BAAS.— A.  f.  O.,  xlv, 
1898.  TREACHER  COLLINS. — T.  O.  S.,  xix,  1899.  *ANARGYROS.— A.  f.  A.,  xlvi,  1902. 


ANGIOMA 

Angiomata  of  the  iris  are  excessively  rare.  In  Mooren's  case  the 
growth  resembled  a  blackberry,  and  bled  profusely  when  the  patient's 
head  was  shaken,  the  hyphsema  disappearing  in  one  and  a  half  minutes. 
After  dwindling  to  one  third  its  former  size  it  set  up  glaucoma,  and  was 
removed  by  iridectomy.  It  was  not  examined  microscopically,  and 
was  looked  upon  by  de  Wecker  as  a  simple  granuloma. 

The  same  explanation  will  apply  to  Schelske's  case,  and  also  to 
Schirmer's  cavernous  angioma.  The  latter  followed  a  wound,  was 
gelatinous  in  appearance,  and  speckled  with  hsemorrhagic  spots. 

Wolfe  describes  a  tumour  similar  to  Mooren's  in  a  man  of  sixty-two, 
which  disappeared  spontaneously  after  seven  months'  duration. 

Berry  reports  a  "  naevus  "  which  involved  not  only  the  iris,  but  also 
a  persistent  pupillary  membrane. 

Alt  records  two  cases :  (i)  a  capillary  angioma,  which  may  have 
been  a  spindle-celled  sarcoma ;  (2)  a  cavernous  angioma,  to  which  the 
same  explanation  will  apply. 


326  THE    PATHOLOGY    OF   THE    EYE 

MOOREN. — Ophthal.  Beobachtungen,  1867.  SCHELSKE. — Lehrbuch,  1870.  SCHIRMER. 
— Greifswalder  med.  Beitrage,  iii ;  G.-S.,  iv,  1876.  WOLFE. — Med.  Times  and  Gazette,  1880. 
BERRY. — Diseases  of  the  Eye,  Edinburgh,  1889.  ALT. — Am.  Jl.  of  Ophth.,  xvii,  1900. 


MYOMA 

Myoma  of  the  iris — independent  of  the  ciliary  body — has,  as  far  as 
I  am  aware,  been  hypothecated  in  only  one  case.  The  tumour  was 
examined  by  Devereux  Marshall  and  diagnosed  as  a  fibre-sarcoma  (Fig. 
229).  Griffith  regarded  it  as  a  myoma.  No  differential  staining 
methods  were  employed.  (See  "  Ciliary  Body")- 


THOMPSON.— T.  O.  S.,  xix,  1899. 


SARCOMA 


Primary  sarcoma  of  the  iris  is  a  rare  disease.  Tay  (1866)  reported 
the  first  case  with  microscopical  examination.  The  recorded  cases 
have  been  collected  by  Knapp  (1879),  Fuchs  (1882),  Treacher  Collins 
(1889),  Ewetzky  (1896),  Werther  (1896),  and  finally  by  Casey  Wood 
and  Brown  Pusey  (1902).  The  last  authors  give  abstracts  of  eighty- 
three  cases  in  which  microscopical  examination  was  made. 

Fuchs  found  sarcoma  of  the  iris  16  times  in  259  collected  cases  of 
sarcoma  of  the  uveal  tract,  Martin  i  in  43,  Lawford  and  Treacher 
Collins  i  in  103  (Moorfields  cases).  Twenty-seven  cases  occurred 
under,  57  over  thirty  years  of  age ;  36  in  males,  45  in  females  (Wood 
and  Pusey).  Melanotic  sarcomata  appear  to  be  commoner  over  forty 
years  of  age,  and  leuco-sarcomata  in  young  patients ;  but  little  stress 
can  be  laid  upon  this  deduction,  both  on  account  of  the  small  number 
of  cases,  and  also  because  pigment  is  often  overlooked  in  so-called 
leuco-sarcomata. 

In  35  cases  the  primary  seat  of  the  tumour  was  in  the  lower  half 
of  the  iris,  in  13  in  the  upper  half,  in  5  in  the  inner  side,  and  in  2  in 
the  outer  side.  It  sometimes  occurs  in  both  eyes  (Brudenell  Carter). 

Sarcomata  of  the  iris  are  usually  melanotic.  They  are  at  first  small, 
and  in  numerous  cases  grow  for  months  or  even  years  without  causing 
vascular  injection  of  the  eye  or  interfering  with  the  mobility  of  the  iris. 
They  are  frequently  nodular,  and  always  very  vascular,  their  vessels 
being  often  visible  to  the  naked  eye.  Sometimes  several  tumour  masses 
occur  in  the  same  iris ;  this  is  probably  due  to  local  dissemination  by 
means  of  the  aqueous-  and  lymph-streams,  not  by  way  of  the  blood. 
Pigmented  and  non-pigmented  nodules  may  appear  side  by  side. 

There  is  at  first  no  iritis,  and  inflammatory  reaction  is  always  slight 
until  secondary  glaucoma  supervenes  in  the  second  stage  of  the  disease. 
In  several  cases  the  first  symptom  drawing  attention  to  the  growth  has 
been  recurrent  haemorrhage  into  the  anterior  chamber;  in  others 
involvement  of  the  pupillary  area  has  led  to  interference  with  vision. 

The  tumour  usually  grows  more  quickly  in  the  later  stages,  some- 
times filling  the  anterior  chamber  or  perforating  the  walls  of  the  globe, 
and  so  leading  to  the  third  stage,  that  of  extra-ocular  growth.  This  is 


THE    IRIS   AND    ANTERIOR   CHAMBER 


327 


usually  brought  about  by  invasion  of  the  ligamentum  pectinatum,  ciliary 
body,  and  the  walls  of  Schlemm's  canal ;  the  cells  then  grow  along  the 
perforating  anterior  ciliary  vessels  and  appear  externally  upon  the 
anterior  part  of  the  sclerotic,  and  therefore,  unlike  tubercle  of  the  iris, 
somewhat  posterior  to  the  limbus.  Early  and  extensive  involvement  of 
the  ciliary  body  often  renders  it  impossible  to  decide  the  primary  seat 
of  the  growth.  Lateral  and  posterior  dislocation  of  the  lens  often  occurs, 
especially  in  growths  starting  in  the  posterior  layers  of  the  iris. 


FIG.  229.— MYOMA  (?)  OF  IRIS,      x    200. 
Thompson,  T.  O.  S.,  xix. 

The  fourth  and  final  stage  is  the  general  dissemination  of  the  disease 
in  other  organs  of  the  body,  almost  invariably  by  way  of  the  blood- 
stream. 

Microscopically  sarcoma  of  the  iris  is  a  diffuse  growth,  and  is  rarely 
and  only  relatively  circumscribed.  In  this  respect  it  differs  from  the 
benign  melanoma,  but  the  difference  may  be  deceptive.  At  the  same 
time  it  almost  invariably  forms  a  definite  tumour,  the  infiltrating  c,r 
flat  type  of  sarcoma  having  been  described  only  as  a  secondary  growth 
in  the  iris  (see  "  Ciliary  Body"). 

The  cells  are  nearly  always  spindle  shaped  or  round,  lying  in  a  tine 
connective-tissue  stroma.  The  spindle-cells  vary  greatly  in  size  and  in 


328 


THE    PATHOLOGY    OF   THE    EYE 


the  amount  of  pigment.  This  is  distributed  in  the  usual  manner  (see 
"  Sarcoma  of  the  Choroid  ").  Eleven  cases  of  leuco-sarcomata  have  been 
recorded,  but  parts  of  melanotic  sarcomata  are  often  unpigmented. 

Pure  round-celled  sarcomata  and  those  with  mixed  round-  and 
spindle-cells  are  uncommon  ;  the  former  are  liable  to  be  mistaken 
histologically  for  inflammatory  conditions,  and  vice  versa.  Karyokinetic 
figures  and  cells  with  two  or  more  nuclei  are  almost  invariably  absent, 
a  striking  difference  from  any  other  sarcomata.  It  is  probably  evidence 
of  the  slow  rate  of  growth,  which  is  further  emphasised  by  a  sort  of 
pseudo-alveolation.  No  trace  of  degenerative  changes  or  inflammatory 
reaction  is  usually  found.  Coleman's  case  (see  Wood  and  Pusey)  of 
"round-celled,  pigmented  sarcoma"  with  marked  oedema  and  infiltra- 
tion with  polymorphonuclear  leucocytes  was  probably  purely  inflam- 
matory. 


FIG.  230. — SARCOMA  OF  IRIS,      x    60. 

The  growth  is  chiefly  spindle  celled,  with  very  little  pigment.     It  has  some 
resemblance  to  Fig.  229,  but  the  nuclei  are  more  oval  than  rod  shaped. 

The  growth  generally  starts  in  the  anterior  layers  of  the  iris,  but 
occasionally  in  the  posterior  layers  (Kerschbaumer).  A  psuedo- 
alveolar  structure  is  often  very  marked ;  the  cells  are  frequently 
arranged  in  rows  and  whorls,  with  little  intercellular  substance.  These 
cells  are  probably  derived  from  the  adventitia  of  the  vessels,  and  many 
of  these  growths  are  peritheliomata.  Most  of  the  pigmented  spindle- 
cells  are  undoubtedly  derived  from  the  stroma-cells  of  the  iris.  In  at 
least  eleven  cases,  and  with  great  probability  in  several  others,  the 
tumours  have  grown  from  congenital  naevi  (Treacher  Collins,  Ewetzky, 
Hirschberg,  Hosch,  Whiting).  Most  of  these  are  probably  melano- 
mata  of  Fuchs's  first  type  (v.  p.  324)  which  have  taken  on  malig- 
nant proliferation.  Whether  any  are  melano-carcinomata  derived 
from  true  naevi  must  be  left  a  matter  of  doubt  until  further  evidence  is 
available.  The  presence  in  the  tumour  of  pigmented  epithelial  cells 


THE    IRIS    AND    ANTERIOR   CHAMBER  329 

derived  from  the  pars  iridica  retinae  must  be  ignored  in  this  connection  ; 
they  are  of  the  same  nature  as  those  found  by  Leber1  in  sarcoma  of  the 
choroid,  derived  from  the  hexagonal  pigment-cells. 

Leuco-sarcomata  of  the  iris  have  been  described  by  Alt,  Treacher 
Collins,  Marshall,  Thalberg,  Limbourg,  and  others.  Limbourg's  case 
showed  the  clinical  picture  of  "  serous  iritis  "  with  keratitis  punctata  ; 
the  deposits  upon  the  back  of  the  cornea  may  have  been  sarcoma-cells 
(v.  Michel). 

Secondary  sarcoma  of  the  iris  is  more  common  than  primary 
(Fig.  263,  p.  368).  It  usually  arises  by  continuity,  but  may  also  be 
metastatic,  and  is  then  probably  invariably  via  the  lymph-stream  and 
not  the  blood.  Multiple  local  metastases  in  the  iris  are  not  very 
uncommon  in  sarcoma  of  the  ciliary  body  (Ginsberg).  Secondary 
sarcoma  by  continuity  often  infiltrates  the  iris  diffusely  without 
forming  any  definite  tumour,  as  in  a  case  which  I  have  reported 
(Fig.  267). 

TAY—  R.  L.  O.  H.  Rep.,  v,  1866.  KNAPP.— A.  of  O.,  viii,  1879.  FUCHS  —  Das 
Sarcom  des  Uvealtractus,  Wien.,  1882.  TREACHER  COLLINS.  — R.  L.  O.  H.  Rep.,  xii,  1889. 
EWETZKY. — A.  f.  O.,  xlii,  i,  1896;  xlv,  3,  1898.  WERTHER.— A.  f.  A.,  xxxii,  1896.  *CASEY 
WOOD  AND  BROWN  PUSEY. — A.  of  O.,  xxxi,  1902.  MARTIN. — Inaug.  Diss.,  Halle,  1885. 
LAWFORD  AND  TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xiii,  1893.  BRUDENELL  CARTER. — 
Med.  Times  and  Gazette,  1874.  KERSCHBAUMER. — Das  Sarcom  des  Auges,  Wiesbaden, 
1900.  HIRSCHBERG. — A.  f.  O.,  xiv,  3,  1868.  HOSCH. — C.  f.  A.,  v,  1881.  WHITING. — A.  of 
O.,  xix,  1890.  ALT. — Amer.  Jl.  of  O.,  1887.  MARSHALL. — T.  O.  S.,  xvii,  1897.  THALBERG. 
— A.  of  O.,  xiii,  1884.  LIMBOURG. — A.  of  O.,  xix,  1890.  PARSONS. — A.  f.  O.,  Iv,  2,  1903; 
A.  of  O.,  xxxiii,  1904.  *LAGRANGE. — Tumeurs  de  1'CEil,  i,  Paris,  1901.  KAYSER. — K.  M.  f.  A., 
xli,  Beilageheft,  1903. 


CARCINOMA 

The  only  epithelial  structure  in  the  iris  is  the  pars  retinalis  iridis  ; 
hence,  according  to  the  received  nomenclature,  primary  carcinoma  of 
the  iris  could  only  originate  in  this  layer.  I  have  already  considered 
melanomata,  which  are  benign  tumours  springing  from  the  stroma  or 
from  the  retinal  epithelium.  When  these  become  malignant  they 
assume  the  characters  of  sarcomata,  and  probably  always  belong  to 
the  first  class ;  whether  the  epithelial  melanomata  become  malignant 
must  be  left  open  to  doubt,  just  as  it  is  doubtful  whether  true  nsevi  of 
the  dermal  type  occur  or  cause  malignant  neoplasms  in  the  iris. 

Extremely  few  records  of  primary  carcinoma  of  the  iris  are  found 
in  the  literature,  and  the  cases  are  all  open  to  other  and,  on  the 
whole,  more  probable  interpretation.  W.  Robertson  described  a 
carcinoma  involving  the  iris  and  ciliary  body  originating  in  the  pig- 
ment epithelium.  Epithelioid  cells,  showing  extensive  colloid  de- 
generation, were  gathered  together  in  groups  surrounded  by  fibrous 
tissue,  thus  giving  the  picture  of  a  scirrhous  cancer.  The  diagnosis  is 
upheld  by  Lagrange,  but  most  authors  would  prefer  to  regard  the 
growth  as  an  endothelioma  or  alveolar  sarcoma  (Emmanuel). 

Hirschberg  and  Birnbacher  described  a  "  spongy  cancer  of  the 
posterior  layer  of  the  iris."  It  occurred  in  a  man  of  twenty-six,  and  was 

1  LEBER. — A.  f.  O.,  xliv,  3. 


330  THE    PATHOLOGY    OF   THE    EYE 

preceded  by  inflammatory  symptoms.  There  was  a  spongy  grey  mass 
on  the  back  of  the  iris  which  displaced  the  lens  backwards.  It  con- 
sisted of  large  epithelial  cells,  with  normal  or  vacuolated  nuclei, 
arranged  in  cords  or  tubes  without  any  intercellular  stroma.  The 
tubes  were  formed  from  the  cords  by  hydropic  degeneration  of  the 
central  cells.  Between  them,  especially  in  the  posterior  part,  was  non- 
nucleated  fibrous  tissue,  containing  wide  blood-channels,  which  did 
not  even  possess  endothelial  walls.  The  fibrous  tissue  was  considered 
to  be  degenerated  vitreous.  Many  of  the  cells  contained  pigment 
granules.  The  iris  showed  chronic  inflammatory  changes,  with  partial 
separation  of  the  two  layers  of  pigment  epithelium,  and  nodules  of 
epithelial  pigment-cells  similar  to  those  of  the  tumour.  The  ciliary 
body  was  compressed,  but  not  involved  in  the  growth. 

The  nature  of  this  neoplasm  is  doubtful.  Emmanuel1  regards  it  as 
inflammatory  ;  Lagrange,  again,  supports  the  author's  diagnosis.  Gins- 
berg points  out  that  it  differs  from  carcinoma  in  growing  only  from  the 
surface  without  invading  other  tissues  and  in  possessing  no  stroma  ; 
and  from  atypical  epithelial  proliferation  of  inflammatory  origin  in 
bursting  the  fibres  of  the  zonule  and  in  forming  isolated  nodules  on  the 
surface  of  the  iris ;  moreover,  the  ciliary  body  showed  no  trace  of 
inflammation.  In  spite  of  these  criticisms,  the  inflammatory  theory 
seems  the  more  probable.  There  was  history  of  inflammatory  attacks, 
and  the  tension  is  said  to  have  been  +2,  neither  of  which  statements 
are  consistent  with  absence  of  signs  of  inflammation  in  the  ciliary 
body.  There  is  also  a  note  of  red  corpuscles,  mononuclear  and,  in 
smaller  numbers,  polynuclear  leucocytes  in  the  fibrous  tissue  about  the 
growth.  Further,  the  structure  is  not  inconsistent  with  inflammatory 
hyperplasia  such  as  is  seen  more  frequently  in  the  ciliary  body  (q.  v.), 
especially  when  combined  with  oedema. 

There  are  several  cases  on  record  of  secondary  carcinoma  of  the  iris 
by  continuity  from  metastatic  growth  in  the  choroid ;  at  the  same 
time  the  iris  is  seldom  implicated  in  these  cases.  In  Ewing's  case  the 
iris  was  largely  transformed  into  fibrous  tissue,  amongst  which  lay 
plugs  of  cancer-cells  ;  there  were  also  nodules  on  the  anterior  surface, 
below  which  the  vessels  were  blocked  with  cancerous  thrombi.  These 
were  found  in  the  posterior  ciliary  arteries  by  Abelsdorff,  but  not  in  the 
iris  vessels.  This  author  and  v.  Michel  consider  that  the  iris  is 
involved  by  dissemination,  not  by  continuity  or  embolism.  There  does 
not  seem  to  be  much  in  favour  of  this  view,  though  in  Lagrange's  case, 
as  also  in  Abelsdorff  s,  the  iridic  tumour  was  not  in  direct  continuity 
with  the  main  growth. 

W.  ROBERTSON. — Ophth.  Rev.,  xiv,  1895.  HIRSCHBERG  AND  BIRNBACHER.— C.  f.  A., 
xx,  1896.  EWING. — A.  f.  O.,  xxxvi,  1890.  ABELSDORFF. — A.  f.  A.,  xxxiii,  1896.  LAGRANGE. 
—  Tumeurs  de  1'CEil,  i,  Paris,  1901. 

1  EMMANUEL. — Virchow's  Archiv,  clxi,  1900. 


THE    IRIS   AND   ANTERIOR   CHAMBER 


331 


TUMOURS  OF  THE  ANGLE  OF  THE  ANTERIOR  CHAMBER 

EXDOTHELIOMA 

Endothelioma   is   the   only  primary   growth    of  the   angle  of  the 


FIG.  231. — ENDOTHELIOMA  OF  LIGAMENTUM  PECTINATUM  IRIDIS.      *    55. 
From  a  specimen  sent  by  Prof.  Fuchs.     This  is  doubtless  the  case  described 
and  figured  by  Hanke  in  A.  f.  O.,  xlvii. 

anterior   chamber,  if  we   except   tubercle.     A  unique  case  has  been 
described  by  Hanke  from  Fuchs's  clinic  (Fig.  231).     It  consisted  partly 


FIG.  232. — GLIOMA  RETINA  IN  ANGLE  OF  ANTERIOR  CHAMBER,      x   55. 

From  a  girl  set  6.  Appearance  of  flocculent  hypopyon  in  lower  angle.  There 
was  extensive  glioma  endophytum.  The  figure  shows  the  lower  false  angle  covered 
with  glioma-cells.  The  nodule  on  Descemet's  membrane,  resembling  k.  p.,  shows 
central  well-stained  cells  and  peripheral  necrotic  cells. 

of  polygonal  endothelial  cells  derived  from  the  ligamentum  pectinatum 
iridis  and  partly  of  spindle-  and  star-shaped  pigmented  cells  and  round 


332 


THE    PATHOLOGY    OF   THE    EYE 


cells.  All  the  cells  were  pigmented,  the  polygonal  least  and  the  round 
cells  most ;  there  were  also  clumps  of  free  pigment  granules  between 
the  cells  and  in  the  vessels.  The  cells  were  arranged  in  an  alveolar 
manner.  The  growth  had  invaded  the  cornea,  iris,  and  ciliary  body, 
and  the  perivascular  lymph-channels  were  pervaded  with  tumour-cells. 
Hanke  considers  that  the  endothelium  is  normally  pigmented  in  this 


FIG.  233. — GLIOMA  RETINAE  COVERING  IRIS,      x    17. 

Narrow  peripheral  anterior  synechia  ;  retro-lental  part  of  globe  full  of  glioma. 
The  iris  is  covered  by  a  thin  layer  of  glioma-cells  lying  upon  minute  capillaries, 
thus  giving  an  arcade-like  appearance.  Note  masses  of  glioma  near  ciliary  pro- 
cesses and  behind  lens. 

situation,  basing  his  observation  on  Rochon-Duvigneaud's  researches, 
though,  as  Ginsberg  points  out,  this  author  speaks  only  of  a  pigmented 
connective-tissue  framework. 
HANKE. — A.  f.  O.,  xlvii,  3,  1899. 

SECONDARY  GROWTHS 

Infective  granulomata — tubercle,  gumma,  etc. — of  the  iris  or 
ciliary  body  often  invade  the  angle  of  the  anterior  chamber. 

So,  too,  sarcoma  of  the  ciliary  body  frequently  invades  the  angle, 
producing  the  clinical  appearance  of  an  irido-dialysis  (see  "  Ciliary 
Body")-  There  is  a  great  tendency  in  some  cases  for  the  infiltration 
to  extend  around  the  whole  circle  of  the  angle,  thus  forming  an  annular 
or  ring  sarcoma  (Meyerhof,  Kopetzky  v.  Rechtperg,  Parsons). 

MEYERHOF. — K.  M.  f.  A.,  xxxix,  1901.  KOPETZKY  v.  RECHTPERG. — A.  f.  O.,  Hi,  2, 
1901.  PARSONS. — A.  f.  O.,  lv,  2,  1903;  A.  of  O.,  xxxiii,  1904. 

Glioma. — Secondary  deposits  are  often  found  in  the  angle  of  the 
anterior  chamber  (Fig.  232)  and  on  the  surface  of  the  iris  in  cases  of 


THE    IRIS   AND    ANTERIOR   CHAMBER  333 

glioma  retinae.  They  are  caused  by  dissemination  of  the  cells  by  the 
lymph-streams,  which  is  so  marked  a  feature  of  this  neoplasm.  I  have 
seen  the  iris  covered  by  a  thin  layer  of  glioma-cells,  which  did  not 
invade  the  structure  itself  (Fig.  233)  ;  the  whole  iris,  indeed,  may  be 
embedded  in  the  growth  and  yet  unaffected  (Wintersteiner).  Actual 
invasion  is  a  very  late  phenomenon.  Wintersteiner  also  found  miliary 
nodules  under  the  pigment  epithelium,  which  was  partly  atrophic  and 
partly  hyperplastic. 

These  superficial  nodules,  in  common  with  those  on  the  choroid, 
Descemet's  membrane,  etc.,  are  non-vascular,  and  therefore  often 
partially  or  totally  necrotic  (see  "Glioma  Retinas"). 

WIXTERSTEINER. — Das  Neuroepithelioma  Retinae,  Wien,  1897. 


CHAPTER    VI 
THE    CILIARY    BODY 

THE    NORMAL    CILIARY    BODY 

THE  ciliary  body  consists  of  two  parts,  the  anterior  folded  part, 
corona  ciliaris,  carrying  the  seventy  to  eighty  ciliary  processes,  and  the 
posterior  smooth  part,  orbicuhts  ciliaris.  In  meridional  section  it 
resembles  an  isosceles  triangle  with  the  apex  backwards ;  here  it  is 
continuous  with  the  choroid.  From  near  the  middle  of  the  base  the 
iris  springs. 

The  ciliary  body  is  composed  chiefly  of  the  ciliary  muscle,  together 
with  vessels  and  nerves  bound  together  by  connective  tissue.  The  vessels 
are  numerous,  the  ciliary  processes  consisting  almost  entirely  of  them, 
reminding  one  of  the  renal  glomeruli.  Most  of  the  vessels  lie  between 
the  ciliary  muscle  and  the  pars  ciliaris  retinae.  The  connective  tissue 
is  fibrillar,  becoming  coarser  and  more  hyaline  in  old  age,  and  contains 
numerous  branched  cells,  many  of  which  are  pigmented.  There  are 
many  elastic  fibres  throughout,  but  they  are  gathered  together  at  the 
outer  part  of  the  base  into  circular  and  oblique  bundles,  which  form  a 
ring  and  are  continuous  with  those  of  the  ligamentum  pectinatum 
iridis.  On  the  inner  side,  the  elastic  fibres  join  an  elastic  lamina,  which 
lies  between  the  ciliary  muscle  and  the  chief  bundles  of  vessels,  passing 
backwards  to  join  the  lamina  vitrea  of  the  choroid.  The  latter  splits 
anteriorly  into  two  layers,  an  outer,  the  elastic  lamina  already 
mentioned,  and  an  inner,  hyaline  non-elastic  membrane,  which  lies 
immediately  beneath  the  retinal  epithelium,  and  is  called  by  Salzmann 
the  outer  hyaline  membrane  (Glashaut)  of  the  ciliary  body.  This  is  to 
distinguish  it  from  an  inner  hyaline  membrane  which  this  author  describes 
lying  upon  the  retinal  epithelium,  continuous  posteriorly  with  the  hya- 
loid membrane  of  the  vitreous  body.  The  fibres  of  the  zonule  of  Zinn 
arise  from  this  inner  hyaline  membrane  (Salzmann).  There  is  a  net- 
work of  elastic  fibres  among  the  vessels  between  the  elastic  lamina 
and  the  outer  hyaline  membrane. 

The  ciliary  muscle  (Bowman)  consists  of  two  parts,  the  outer 
meridional,  Briicke's  muscle,  and  the  inner  circular,  Midler's  muscle.  Both 
are  made  up  of  unstriped  fibres,  and  are  variously  developed  in 
different  eyes,  the  former  most  in  myopic,  and  the  latter  in  hyper- 
metropic  eyes.  The  difference  in  development  is  present  in  the  new- 
born (Lange).  Briicke's  muscle  arises  from  the  sclerotic  internal  and 


THE    CILIARY    BODY 


335 


posterior  to  Schlemm's  canal,  and  is  gradually  lost  posteriorly  in  the 
external  layers  of  the  choroid ;  hence  the  term  tensor  choroideae 
(Briicke).  Waldeyer  describes  a  small  outer  portion  inserted  into  the 


FIG.  234. — GLANDS  OF  THE  CILIARY  BODY,      x   120. 
From  Treacher  Collins.     Bleached  section  of  normal  human  ciliary  body. 

sclerotic,  homologous  with  the  Grampian's  muscle  of  birds.     The  ciliary 
muscle  consists  of  striped  fibres  in  birds. 

The  pars  ciliaris  retina,  covering  the  inner  surface  of  the  ciliary  body, 
consists  of  two  layers  of  the  epithelium,  corresponding  with  the  two  layers 
of  the  secondary  optic  vesicle.  The  outer  layer  is  pigmented,  the  cells 
being  higher  than  those  covering  the  choroid,  except  at  the  tips  of  the 
ciliary  processes.  The  inner  layer  is  non-pigmented,  the  cells  being 


FIG.  235, — GLANDS  OF  CILIARY  BODY,      x  300. 
From  Treacher  Collins.     Bleached  section  of  normal  eye. 

cubical  or  cylindrical.  The  epithelium  lies  upon  the  outer  hyaline  mem- 
brane, which  has  irregular  thickenings  upon  its  inner  surface,  forming  a 
sort  of  reticulum,  which  has  large  meshes  in  the  posterior  part  of  the  orbi- 


336  THE    PATHOLOGY   OF   THE    EYE 

culus  and  smaller  meshes  near  the  corona.  The  reticulum  is  best  seen  at 
about  fourteen  years  of  age  (Kuhnt,  Salzmann).  The  meshes  are  filled  in 
with  pigment  epithelium,  and  when  this  is  bleached  the  depressions  re- 
semble glands.  These  are  the  glands  of  the  ciliary  body  (Treacher  Collins) 
(Figs.  234,  235) ;  they  pass  down  towards  the  elastic  lamina,  seldom 
below  it. 

KUHNT. — K.  M.  f.  A.,  xix,  1881.  TREACHER  COLLINS. — T.  O.  S.,  xi,  1891  ;  Ophth. 
Rev.,  xv,  1896;  Researches,  London,  1896;  see  also  NICATI,  A.  d'O.,  x,  1890;  xi,  1891; 
BUCHANAN,  jl.  of  Anat.  and  Phys.,  xxxi.  GRIFFITH. — Ophth.  Rev.,  xiii,  1894.  ALT. — Am. 
Jl.  of  Ophth.,  xiii,  1896.  SALZMANN. — Die  Zonula  ciliaris  u.  ihr  Verhaltniss  zur  Umgebung, 
1900.  LANGE. — K.  M.  f.  A.,  xxxix,  1901. 


WOUNDS 

Wounds  of  the  ciliary  body  are  of  peculiar  interest  to  the  clinician, 
and  have  received  much  attention  from  the  clinical  standpoint  on 
account  of  their  liability  to  set  up  sympathetic  ophthalmia.  They  are 
often  associated  with  prolapse  of  the  iris  and  ciliary  processes,  resulting 
in  iritis  and  cyclitis.  The  microscopical  changes  accompanying  trau- 
matic cyclitis  are  described  elsewhere  (v.  infra}.  It  often  goes  on 
to  suppuration  and  the  loss  of  the  eye.  In  cases  where  infection  is 
avoided  the  wounds  heal  rapidly,  as  might  be  expected  in  so  vascular  a 
tissue.  The  process  of  healing  resembles  that  of  the  choroid,  which 
will  be  treated  fully  in  considering  wounds  of  the  retina.  The  pars 
ciliaris  retinae  takes  no  part  in  the  process  at  all,  except  that  the 
pigment-cells  of  this  layer  sometimes  show  proliferation,  but  only  in 
slight  degree.  The  sclerotic,  too,  is  absolutely  inert,  the  edges  being 
clean  cut  though  slightly  rounded  off,  and  the  new  cells  running  almost 
entirely  at  right  angles  to  them  (Fig.  236).  The  ciliary  body 
provides  fibroblasts  for  a  modicum  of  the  scar  tissue  ;  others  are  derived 
from  the  episcleral  tissue.  Some  proliferation  of  the  pigment-cells 
occurs ;  pigment  is  found  in  small  quantities  scattered  through  the 
scar,  mostly  as  free  granules,  some  in  leucocytes,  and  some — the 
smallest  part — in  pigment-cells,  most  of  which  are  of  uveal  origin, 
though  some  appear  to  be  retinal. 

PARSONS. — R.  L.  O.  H.  Rep.,  xv,  3,  1903. 


INFLAMMATION 

ACUTE  AND  SUPPURATIVE 

Acute  and  suppurative  cyclitis  are  seen  after  perforating  wounds  of 
the  globe,  corneal  ulcers,  in  panophthalmitis,  etc.  ;  there  is  no  sharp 
limit  anatomically  between  the  two  conditions. 

The  first  sign  of  acute  cyclitis  is  intense  hyperaemia,  with  dilatation 
of  the  vessels,  which  are  packed  with  red  corpuscles  and  surrounded 
by  leucocytes,  these  being  also  more  numerous  inside  the  vessels.  The 
connective  tissue  is  most  affected,  the  ciliary  muscle  escaping  to  a  large 
extent.  The  former  is  cedematous  and  densely  crowded  with  mono-  and 


THE    CILIARY    BODY 


337 


polymorphonuclear  leucocytes,  which  obscure  the  normal  structures. 
The  mast-cells,  which  are  normally  present  in  small  numbers,  are  much 
multiplied.  Even  in  very  early  stages,  e.  g.  during  the  first  hours  after 
an  injury,  the  leucocytes  are  not  confined  to  the  ciliary  body  itself,  but 
penetrate  between  the  retinal  epithelial  cells  and  escape  into  the 
vitreous,  the  posterior  chamber,  etc.  (Figs.  237,  sqq.),  and  are  carried  by 
the  lymph-stream  into  the  anterior  chamber,  where  they  may  accumulate 
and  form  an  hypopyon.  The  iris  is  invariably  inflamed  in  greater 
or  less  degree.  The  lymph  secreted  by  the  inflamed  ciliary  processes 
contains  an  excess  of  proteids,  and  is  readily  coagulable.  The  coagulum 
varies  greatly  in  the  amount  of  fibrin  present.  This  may  be  almost 
absent,  so  that  the  hypopyon  is  fluid  ;  in  this  case  the  cells  may  break 


FIG.  236. — WOUND  OF  THE  CILIARY  BODY,      x  25. 

Parsons,  R.   L.  O.    H.   Rep.,  xv,  3.     Perforating  wound  of  ciliary  body  of  a 
monkey,  made  with  a  Graefe  knife  fourteen  days  previously ;  equatorial  section. 

up  and  pass  away  through  the  normal  channels  of  excretion  at  the 
angle  of  the  anterior  chamber,  though  they  are  frequently  reinforced 
and  a  fresh  hypopyon  forms.  In  the  more  acute  and  more  plastic 
forms  of  inflammation  the  exudate  in  the  vitreous,  amongst  the  fibres 
of  the  zonule,  in  the  posterior  chamber,  pupillary  area,  and  anterior 
chamber,  may  be  composed  of  a  dense  network  of  fibrin  containing 
leucocytes  in  its  meshes  (Fig.  244).  The  more  solid  hypopyon  present 
under  these  conditions  is  less  readily  disposed  of,  and  may  subsequently 
organise.  Still  more  resistant  are  the  coagula  behind  the  iris,  and  it  is 
around  the  lens  in  this  situation  that  the  first  traces  of  fibrous  organisa- 
tion appear,  even  as  early  as  the  eighth  day  (Buchanan)  (Fig.  243). 

It  can  scarcely  be  doubted  that  the  infiltrating  cells  are  entirely  of 
haemal  or  lymphatic  origin  :  the  development  of  leucocytes  from  endo- 

22 


338 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  237. — CYCLITIS.      x  9. 

Buchanan,  T.  O.  S.,  xxi.    Cyclitis  of  fourteen  days'  duration, 
vitreous,  lying  upon  the  ciliary  body,  retina  and  lens  capsule. 


Exudate  in  the 


FIG.  238. — CYCLITIS.      x    14. 

Buchanan,  T.  O.  S.,  xxi.  Cyclitis  of  many  years'  duration.  Corneo-scleral 
junction  above  to  right;  lens  above  to  left.  Below  the  lens  is  a  mass  of  fibrous 
tissue  with  the  ciliary  body  to  the  right,  and  the  detached  and  folded  retina  below. 


THE    CILIARY    BODY 


339 


FIG.  239. — CYCLITIS.      x   100. 

Buchanan,  T.  O.  S.,  xxi.     Cyclitis  of  twenty  days'  duration.     Section  of  pars 
oiliaris  retinae,  showing  the  process  of  deposition  of  the  exudate. 


FIG.  240. — CYCLITIS.      x    100. 

Buchanan,  T  .O.  S.,  xxi.     Cyclitis  of  sixteen  days'  duration.     Section  bleached 
with  euchlorine. 


340 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  241. — CYCLITIS.      x   120. 

Buchanan,  T.  O.  S.,  xxi.  Cyclitis  of  twenty-two  days'  duration.  Showing  the 
inner  surface  of  the  retina  and  separation  of  the  vitreous,  with  large  epithelioid  cells 
lying  in  the  intervening  space. 


FIG.  24.2. — CYCLITIS.      x    120. 

Buchanan,  T.  O.  S.,  xxi.      Cyclitis  of  twenty-two  days'  duration.     Showing  the 
inner  surface  of  the  retina  and  the  vitreous. 


THE    CILIARY    BODY 


FIG.  243. — CYCLITIS.      x  200. 

Buchanan,  T.  O.  S.,  xxi.     Cyclitis  of  sixty  days'  duration.     Pars  ciliaris  retinas 
above.     Showing  the  formation  of  fibrous  tissue  in  the  exudate. 


FIG.  244. — CYCLITIS.     x  100. 

Buchanan,  T.  O.   S.,  xxi.      Cyclitis    of  eighteen    days'  duration, 
fibrinous  exudate  below. 


Showing 


342  THE    PATHOLOGY    OF   THE   EYE 

thelium  and  fixed  tissue-cells  (Reid,  Buchanan)  is  opposed  to  the 
opinions  of  the  best  pathologists.  In  suppurative  cyclitis  the  poly- 
morphonuclear  leucocytes  are  greatly  in  excess,  and  are  densely  aggre- 
gated upon  the  surface  of  the  ciliary  body  (Fig.  193,  p.  293). 

The  two  layers  of  epithelium  upon  the  ciliary  processes  are  often 
separated  by  exudate,  and  this  occurs  more  frequently  than  in  the  iris. 
Both  layers  of  epithelium  may  also  be  raised  from  the  rest  of  the 
ciliary  body  by  exudate.  In  this  manner  quite  large  cystic  spaces  may 
be  formed ;  they  have  been  found  after  puncture  of  the  anterior 
chamber  in  rabbits  (Greeff)  (v.  infra). 

Desquamation  of  the  epithelium  is  found,  and  this  especially  affects 
the  pigmented  layer.  The  cells  break  up  and  set  free  their  pigment 
granules,  which  are  disseminated  amongst  the  cells  and  are  largely  taken 
up  by  leucocytes.  It  is  not  uncommon  to  find  the  ciliary  processes  almost 
entirely  deprived  of  their  pigment,  especially  in  cases  of  panophthalmitis, 
and  the  glands  of  the  ciliary  body  may  often  be  well  demonstrated. 

In  the  more  severe  cases  the  inflammation  is  not  confined  to  the 
anterior  part  of  the  eye,  but  a  condition  of  panophthalmitis  is  set  up. 
The  retina  then  becomes  inflamed ;  its  vessels  are  dilated  and  sur- 
rounded by  leucocytes,  which  may  later  add  their  quotum  to  the  exudate 
in  the  vitreous. 

Organisation  of  the  exudate  resembles  cicatrisation  in  other  parts 
of  the  body.  Fibroblasts  are  formed  from  the  fixed  connective-tissue 
cells,  and  invade  the  exudate,  manifesting  themselves  as  large  spindle- 
or  star-shaped  cells  (Fig.  243).  There  is  no  good  evidence  that  the 
cubical  cells  of  the  retinal  epithelium  contribute  to  the  formation  of 
fibrous  tissue,  as  stated  by  Alt.  They  are  often  dragged  out  and  appear 
cylindrical.  New  blood-vessels  are  formed  in  the  usual  manner,  solid 
processes  being  given  off  from  the  capillary  walls.  These  become 
canalised,  and  appear  as  simple  endothelial  tubes,  which  later  assume 
an  adventitial  connective-tissue  sheath.  The  fibrous  tissue  increases 
rapidly,  being  loose  and  cellular  at  first,  with  fine  wavy  fibrils  and  often 
large  hyaline  masses,  especially  in  the  vitreous.  In  the  later  stages, 
and  in  some  cases  relatively  early,  dense  masses  of  closely  packed 
fibres  with  few  cells  or  blood-vessels  are  laid  down.  This,  in  typical 
cases,  forms  a  thick  membrane  behind  the  lens,  being  attached  to  the 
ciliary  body  on  each  side,  and  frequently  sending  off  processes  which 
are  attached  to  the  retina.  During  the  contraction  which  always 
accompanies  the  consolidation  of  such  tissue  the  ciliary  processes 
are  drawn  inwards,  and  the  whole  ciliary  body  is  often  detached  from 
the  sclerotic,  except  at  the  spot  where  the  ciliary  muscle  is  inserted 
into  the  sclerotic  just  behind  the  angle,  leaving  a  large  supra-ciliary 
space,  traversed  by  fine,  more  or  less  concentric  laminae  of  pigmented 
stroma.  The  retina  is  also  detached  by  the  same  process,  the  globe 
finally  shrinking  and  entering  into  the  condition  known  as  phthisis  bulbi. 

A  less  common  metamorphosis  of  the  exudate  is  seen  in  the 
formation  of  lamellae  of  homogeneous  material,  separated  by  flattened, 
branched  cells. 

In  all  types  there  is  frequently  marked  proliferation  of  the  pars 
ciliaris  retinae  into  the  scar  tissue.  Long,  branching,  pigmented  bands 


THE    CILIARY    BODY 


343 


are  thus  formed  (Alt)  ;  these,  on  bleaching,  are  seen  to  consist  of  tubules 
lined  with  cylindrical  or  flattened  epithelium  (Figs.  245 — 7).  They 
arise  chiefly  from  the  pars  plana,  and  give  the  appearance  of  proliferation 
of  the  glands  of  the  ciliary  body  (Treacher  Collins)  (Fig.  245).  Blood- 
corpuscles  may  occasionally  be  seen  inside  similar  pigmented  tubules 
lined  with  flattened  cells,  so  that  these  tubes  are  probably  new-formed 
blood-vessels,  the  pigment  around  them  being  haematogenous.  In  some 
cases  plugs  or  tubes  of  non-pigmented  epithelium  are  seen  in  the  same 
situation,  derived  from  the  retinal  epithelium.  There  is  some  evidence 
that  these  may  later  become  pigmented  (Treacher  Collins). 


FIG.  245. — TUBULES  IN  CYCLITIC  MEMBRANE. 
From  Treacher  Collins. 


300. 


The  lens  is  often  completely  embedded  in  dense  fibrous  tissue,  which 
occludes  the  pupil,  leads  to  total  posterior  synechia  and  the  formation 
of  a  cyclitic  membrane  in  the  vitreous.  The  lens  capsule  remains 
intact,  though  it  is  often  wavy  and  folded  owing  to  the  degenerative 
changes  which  take  place  in  the  lens  and  lead  to  shrinking.  The  lens 
under  such  circumstances  may  become  calcareous,  but  never  bony,  as 
long  as  the  capsule  is  intact ;  this  apparently  forms  a  barrier  impassable 
to  osteoblasts. 

The  various  stages  of  exudation  and  organisation  may  often  be  seen 
simultaneously  in  different  parts  of  the  same  section.  The  part  nearest 
the  ciliary  body  naturally  organises  first,  since  it  is  from  this  part  that 
the  fibroblasts  are  derived.  Here  the  fibrous  tissue  lies  upon  the 
broken  up  and  distorted  retinal  epithelium,  between  the  cells  of  which 


THE    PATHOLOGY    OF   THE    EYE 


FIG.  246. — TUBULES  IN  CYCLITIS.      x  55. 

Contusion  twenty  years  before  excision.  On  the  right,  sclerotic.  To  the  left  of 
this  non-pigmented  tubules  are  seen  growing  from  the  pars  plana  into  a  mass  of 
post-cyclitic  fibrous  tissue.  The  fibrous  tissue  to  the  left  is  more  cellular,  and  has 
undergone  fatty  degeneration. 


FIG.  247.— TUBULES  IN  CYCLITIS.      x  60. 

Cyclitis  of  thirty-five  years'  duration.  The  sclerotic  is  to  the  left  beyond  the 
field.  Pigmented  tubules  in  dense  post-cyclitic  fibrous  tissue.  The  amount  of 
pigment  varies,  and  is  absent  from  some  of  the  tubules. 


THE    CILIARY    BODY 


345 


FIG.  248. — CYCLITIS.      x    100. 

Buchanan,  T.  O.  S.,  xxi.     Cyclitis  of  two  and  a  half  months'  duration, 
ing  fatty  degeneration  of  the  exudate. 


Show- 


FIG.  249. — CYCLITIS.      x   15. 

Buchanan,  T.  O.  S.,  xxi.     Cyclitis  after  seventeen  years.     Showing  true  bone 
in  the  curve  of  the  displaced  ciliary  body. 


346  THE    PATHOLOGY    OF   THE   EYE 

blood-vessels  pass.  Internal  to  the  fibrous  tissue  is  a  fibrinous  cellular 
exudate  (Fig.  243). 

Buchanan  describes  five  types  of  cell  in  the  exudate,  and  explains 
their  origin  as  follows: — (i)  A  multinuclear  cell  with  finely  granular 
protoplasm  actively  engaged  in  proliferation  :  a  leucocyte  or  dividing 
mononuclear  cell ;  (2)  a  mononuclear  cell,  which  proliferates :  a 
lymphocyte  (a)  of  vascular  origin,  (b)  a  bud  from  other  exudation-cells, 
(c)  a  bud  from  fixed  cells ;  (3)  a  large  epithelioid  cell,  occasionally  di- 
viding :  a  retinal  epithelial  cell ;  (4)  a  small  round  mass  of  nuclear 
matter,  probably  a  young  cell :  a  bud  ;  (5)  a  large  mass  of  more  or  less 
ill-defined  protoplasm  without  nucleus,  or  "  ghost-cell :  "  the  cytoplasm 
from  which  a  nucleus  has  passed  out.  He  considers  that  nuclear 
activity  is  displayed  by  (a)  gemmation,  or  budding,  (b)  fission,  (c) 
fragmentation,  (d)  emigration ;  karyokinesis  is  not  seen,  being  too 
slowa  method  of  cell-division.  Buchanan's  observations  and  prepara- 
tions are  of  great  value,  but  his  deductions  are  not  wholly  in  accord 
with  generally  accepted  views. 

Degenerative  changes  occur  in  the  exudate  and  cicatricial  tissue. 
The  earliest  of  these,  apart  from  fragmentation  of  nuclei,  which  is  a 
sign  of  necrosis,  is  fatty  degeneration  (Buchanan)  (Fig.  248).  Lime- 
salts  are  frequently  deposited  in  the  membranes  and  fibrous  masses, 
first  as  fine  granules  or  concretions  which  stain  very  deeply  with 
hsematoxylin  and  other  dyes  containing  alum  (Figs.  250,  251).  At  a 
later  stage  true  bone  may  be  formed  (Figs.  249 — 253). 

Bone  formation  in  scars  is  of  extreme  rarity  in  other  parts  of  the 
body.  It  frequently  occurs  in  degenerative,  usually  post-cyclitic, 
conditions  in  the  choroid.  It  would  seem  as  if  the  choroid  and  in  less 
degree  the  ciliary  body  possess  the  capacity  of  forming  osteoblasts 
from  their  fixed  cells  instead  of  fibroblasts  under  definite  conditions  of 
prolonged  irritation  and  degeneration.  The  formation  of  bone  in 
cyclitic  deposits  is  comparatively  rare.  It  commences  in  the  depo- 
sition of  spherical  globules,  usually  in  proximity  to  a  blood-vesse  . 
The  granules  coalesce  and  form  a  homogeneous  mass,  which  .may  be 
shown  to  contain  calcium  carbonate  (Fig.  251).  The  edges  are  ragged 
and  terminate  in  globules,  which  diminish  in  size  as  they  are  farther 
from  the  mass. 

At  an  early  stage  long  delicate  fibres,  and  occasionally  stellate 
corpuscles  may  be  seen  lying  between  the  globules  and  radiating  from 
the  mass  into  the  surrounding  tissue  (Fig.  253).  These  are  evidently 
comparable  with  osteogenetic  fibres  and  osteoblasts  (Buchanan).  The 
more  advanced  portion  of  the  mass  early  encloses  the  blood-vessel,  and 
soon  shows  a  marked  change  in  structure ;  it  becomes  striated  con- 
centrically around  the  irregular  cavity  in  which  the  blood-vessel  lies 
(Fig.  252). 

At  a  later  stage  the  spaces  are  seen  to  be  lined  with  osteoblasts 
regularly  arranged,  and  to  contain,  besides  the  blood-vessel,  fat  and 
sheaves  of  fatty  crystals.  In  the  completely  formed  bone  the  cavities 
are  more  open  and  the  lamination  is  more  marked.  The  growing  edge 
of  the  bone  continues  to  be  ill  defined,  and  consists  usually  of  a  series  of 
fibres,  which  pass  outwards  into  the  surrounding  fibrous  tissue.  The 


THE   CILIARY    BODY 


347 


FIG.  250. — CYCLITIS.      x    15. 

Buchanan  T  O.  S.,  xxi.  Cyclitis  after  eleven  years.  Showing  an  early  stage 
in  the  formation  of  bone  in  the  exudate.  The  upper,  less  advanced  part  is  opaque 
and  granular ;  the  lower,  more  advanced  part  bears  some  resemblance  to  bone. 


Buchanan,  T.  O.  S.,  xxi. 
of  calcareous  particles. 


FIG.  251.— CYCLITIS. 
Cyclitis  after  eleven  years. 


Showing  the  deposition 


THE    PATHOLOGY   OF   THE    EYE 


FIG.  252. — CYCLITIS.      x   150. 

Buchanan,  T.  O.  S.,  xxi.     Cyclitis  after  thirteen  years.     Showing  the  structure 
of  fully  formed  bone.     A  cavity  lined  with  osteoblasts  is  seen. 


FIG.  253. — CYCLITIS.      x   150. 

Buchanan,  T.  O.  S.,  xxi.     Cyclitis  after  twenty  years.     Showing  the  connec- 
tions of  advancing  bone  formation.     Fibres  are  spread  out,  with  cells  between  them. 


THE    CILIARY    BODY 


349 


cells   arrange    themselves    in  columns  around  these  fibres,  and   both 
appear  to  be  surrounded  by  calcareous  deposit. 

ALT. — Lectures  on  the  Human  Eye,  New  York,  1880.  TREACHER  COLLINS. — Re- 
searches into  the  Anatomy  and  Pathology  of  the  Eye,  London,  1896.  *BUCHANAN. — 
T.  O.  S.,  xxi,  1901. 


CHRONIC   CYCLITIS 

Chronic  cyclitis,  or  irido-cyclitis,  occurs  in  two  forms  :  (i)  serous 
cyclitis,  often  called  "  serous  iritis  "  ;  (2)  chronic  plastic  cyclitis,  which  is 
merely  a  subacute  or  chronic  plastic  cyclitis,  similar  in  its  essentials 
with  the  non-suppurative  forms  of  acute  cyclitis. 

The  characteristic  physical  sign  of  serous  cyclitis  is  the  presence  of 
deposits  upon  the  back  of  the  cornea,  commonly  known  by  the  ill- 
chosen  term,  keratitis  punctata  (Sichel).  These  precipitates  appear  as 
minute  greyish  dots  scattered  irregularly  upon  Descemet's  membrane, 
but  mostly  over  a  triangular  area  of  the  lower  part ;  the  base  of  the  tri- 
angle corresponds  with  the  lower  corneal  margin,  the  apex  being 
directed  upwards  towards  the  centre  of  the  cornea.  The  larger  deposits 
are  usually  below,  the  more  numerous  finer  ones  above,  but  the  typical 
arrangement  is  often  wanting.  The  spots  are  frequently  pigmented, 
looking  brown  or  reddish.  Larger  aggregations  occur  in  older  cases, 
and  the  deposits  then  often  assume  a  yellowish  gelatinous  appearance, 
sometimes  known  in  England  as  "  mutton-fat  k.  p." 

These  deposits  have  long  been  recognised.  They  were  first 
accurately  described  by  Wardrop  (1808),  and  attributed  by  him  to 
inflammation  of  Descemet's  membrane — Descemetitis,  hydromeningitis, 
aquocapsulitis,  keratitis  punctata.  Ruete  (1845)  and  Stellwag  v.  Carion 
first  pointed  out  that  inflammation  of  a  structureless  membrane  like 
Descemet's  cannot  occur,  and  further  that  this  membrane  does  not 
extend  over  the  iris  and  has  nothing  to  do  with  the  secretion  of  aqueous. 
Arlt  (1853)  regarded  the  deposits  as  a  product  of  iritis,  and  v.  Graefe 
(1856)  showed  ophthalmoscopically  the  frequent  participation  of  the 
choroid  in  the  inflammation  in  these  cases. 

Schweigger  (1873)  and  Iwanoff  (1876)  give  the  first  description  of 
the  microscopic  appearances,  which  they  considered  due  to  the  pro- 
liferation of  the  endothelium  of  Descemet's  membrane. 

de  Wecker  (1876)  describes  a  fibrinous  exudate  as  occurring  first  at 
the  spots,  followed  later  by  proliferation  of  the  endothelial  cells.  Knies 
(1880)  found  small  groups  of  round-cells,  under  which  the  endothelium 
was  intact  and  unchanged ;  in  later  stages,  and  in  the  case  of  larger 
deposits,  the  endothelium  had  disappeared,  and  the  round-cells  showed 
degenerative  changes,  their  contours  being  indistinct.  He  observed 
similar  exudates  upon  the  surface  of  the  ciliary  body,  but  doubted  their 
ability  to  traverse  the  zonule  of  Zinn.  He  therefore  attributed  those  on 
the  back  of  the  cornea  to  iritis  ;  we  now  know  that  such  exudates  can  be 
readily  carried  forwards  by  the  lymph-stream,  passing  between  the  fibres 
of  the  zonule,  which  does  not  form  an  impenetrable  membrane.  Fuchs 
(1884)  first  brought  forward  incontrovertible  anatomical  evidence  that  the 


350  THE    PATHOLOGY   OF   THE    EYE 

deposits  are  a  sign  of  chronic  cyclitis,  and  that  they  are  chiefly  derived 
from  the  ciliary  body.  He  found  them  to  consist  of  aggregations  of 
leucocytes  (Fig.  254),  many  of  which  contained  pigment  granules,  show- 
ing their  origin  from  the  uveal  tract.  The  cells  usually  have  large 
nuclei  and  a  small  amount  of  cytoplasm,  so  arranged  as  to  resemble  a 
signet-ring.  The  precipitates  lie  upon  the  endothelium  of  Descemet's 
membrane,  which  is  at  first  quite  normal ;  later,  and  under  larger 
deposits,  the  endothelium  degenerates  and  disappears.  The  endothe- 
lium is  therefore  not  in  most  cases  the  active  cause  of  the  deposits.  In 
late  stages  the  cells  undergo  fatty  degeneration  and  become  absorbed, 
leaving  the  pigment  granules  behind.  These  then  appear  as  fine  pig- 
mented  spots.  Schweigger  (1885)  described  proliferation  of  the  endo- 
thelium around  the  deposits  ;  he  considered  them  to  consist  of  detritus 


FIG.  254. — "KERATITIS  PUNCTATA."      x  200. 

"  Mutton-fat  k.  p."  from  case  of  irido-cyclitis.  The  figure  shows  a  mass  of 
leucocytes  on  Descemet's  membrane,  the  endothelium  of  which  is  intact.  The 
centre  of  the  mass  consists  of  fibrin  and  granular  material,  the  periphery  of  fibrin. 
There  were  many  such  nodules  in  the  lower  part  of  the  a.  c. 

and  degenerated  cells  deposited  on  the  back  of  the  cornea,  and  easily 
washed  off,  e.g.  by  the  escape  of  aqueous  on  puncturing  the  anterior 
chamber.  Snellen,  Jr.  (1894)  found  groups  of  bacteria  in  the  de- 
posits ;  this  observation  has  not  been  confirmed  for  ordinary  keratitis 
punctata,  and  must  be  of  rare  occurrence.  Ridley  (1895)  confirms  the 
results  of  earlier  observers,  including  the  normal  condition  of  the  endo- 
thelium in  the  early  stages.  That  proliferation  of  the  endothelium 
may,  however,  occur  has  been  shown  by  Uhthoffand  Axenfeld  (1896). 
They  obtained  warty  endothelial  growths  after  inoculation  of  pneumo- 
cocci  into  the  anterior  chamber  of  rabbits.  Groenouw  (1900)  found 
pigment  granules  partly  within  and  partly  outside  the  cells;  he  also 


THE    CILIARY    BODY  351 

found  giant-cells,  or  bodies  resembling  them,  and  a  network  of  fibrin 
between  the  cells  and  often  lying  upon  the  intact  endothelium,  which  he 
thinks  plays  a  purely  passive  part. 

Whilst  the  leucocytes  which  form  these  precipitates  are  commonly 
derived  mainly  from  the  ciliary  body,  Baas  (1903)  has  adduced  good 
evidence  that  they  may  come  from  the  iris  alone.  In  his  case  there  was 
total  posterior  synechia,  and  a  fresh  attack  of  inflammation  was 
followed  by  new  deposits ;  these  could  not  have  passed  through  the 
iris,  but  must  have  been  derived  from  it. 

The  pigment  was  derived  by  Leber  (1879)  from  degenerated  red 
corpuscles;  in  the  majority  of  cases  it  is  undoubtedly  uveal  (Knies, 
Fuchs,  Groenouw).  Probably  it  may  originate  from  either  source. 


>'-,;-.  ;.v         . 


FIG.  255. — "  KERATITIS  PUNCTATA."      x  55. 

From  a  case  of  dislocated  lens.  The  figure  shows  the  lower  part  of  the  ciliary 
body,  covered  with  swollen  leucocytes,  undergoing  hyaline  degeneration.  Large 
nodules  of  the  same  cells  were  present  over  the  lower  part  of  Descemet's  membrane. 
Note  the  degeneration  of  the  iris  and  ciliary  body.  The  section  was  stained  by  van 
Gieson,  and  shows  the  dense  bands  of  fibrous  tissue  in  these  structures. 

The  larger  deposits  of  long  standing,  which  are  known  clinically  as 
"  mutton-fat  k.  p.,"  show  a  hyaline  degeneration  of  the  cells  (Fig.  255). 
These  are  swollen,  and  run  together  more  or  less;  the  nuclei  stain  badly 
or  not  at  all,  though  their  outlines  can  often  be  made  out  dimly.  The 
masses  stain  with  cytoplasmic  stains,  but  diffusely  with  nuclear  stains. 

There  can  be  little  doubt  that  the  cells  are  deposited  centrifugally 
upon  the  back  of  the  cornea,  and  that  the  movements  of  the  eyes  are  a 
factor  in  determining  their  arrangement  (Arlt).  The  spots  are 
occasionally  seen  upon  the  lens  capsule ;  it  would  be  impossible  for 
them  to  be  derived  here  from  endothelium,  but  the  absence  of 


352 


THE    PATHOLOGY    OF   THE    EYE 


endothelium  may  account  for  the  infrequency  of  their  occurrence  in 
this  situation.  It  is  probable  that  in  the  conditions  under  which  they 
occur  the  endothelium  of  Descemet's  membrane  is  irritated  and 
becomes  sticky,  so  that  the  leucocytes  readily  adhere  to  it. 

Deposits  resembling  keratitis  punctata  may  arise  from  other  causes, 
usually  malignant  growths,  v.  Michel  describes  a  round-celled  sarcoma 
of  the  ciliary  body  in  which  nodules  of  tumour-cells  were  found  upon 
the  back  of  the  cornea,  the  endothelium  being  normal.  Similar 
deposits  of  glioma-cells  may  occur  (v.  p.  333). 

Whilst  the  aqueous  in  serous  cyclitis  is  richer  in  proteids  than  the 
normal  fluid,  yet  there  is  less  tendency  to  coagulation  than  in  acute 
cyclitis.  The  inflammation  is  more  of  the  catarrhal  than  the  plastic 


FIG.  256.— CYCLITIS,  SHOWING  RETRACTION  OF  THE  IRIS  AT  THE  PERIPHERY,  x  25. 
Cornea  in  front  to  left ;  peripheral  anterior  synechia,  retraction  of  periphery  of 
iris.  The  iris  is  degenerated  ;  note  the  new  fibrous  membrane  on  anterior  surface, 
most  marked  near  pupillary  edge,  to  right;  also  "ectropion  of  uvea."  The  ciliary 
processes  are  dragged  inwards  and  lie  in  a  mass  of  almost  non-cellular  fibrous 
tissue,  which  fills  the  posterior  chamber  and  replaces  the  vitreous.  The  material 
to  the  right  below  is  coagulum  behind  the  detached  atrophic  retina. 


Such 


considerations 
of  the 


type,  and  the  exudate  is  relatively  poor  in  fibrin, 
have  led  Treacher  Collins  to  regard  the  conditi 
glands  of  the  ciliary  body. 

The  anatomical  changes  which  occur  in  the  ciliary  body  differ 
chiefly  in  degree  from  those  found  in  acute  cyclitis.  The  ciliary  pro- 
cesses are  moderately  swollen,  and  may  touch  the  back  of  the  iris 
(Fuchs).  The  tissues  are  infiltrated  with  leucocytes,  which  are  chiefly 
arranged  around  the  blood-vessels,  but  may  also  occur  in  nodular 
masses,  especially  in  the  posterior  part  of  the  ciliary  body.  These  con- 
sist mostly  of  mononuclear  lymphocytes,  and  are  found  especially 


THE    CILIARY    BODY  353 

between  the  ciliary  muscle  and  the  pigment  epithelium.  The  latter 
may  be  little  altered,  the  exuded  cells  passing  between  the  epithelial 
cells  into  the  vitreous.  Here  they  form  masses  on  the  inner  surface  of 
the  ciliary  body,  especially  in  the  depressions  between  the  processes 
and  folds  ;  others  lie  free  on  the  surface,  and  in  every  respect  resemble 
the  deposits  on  the  back  of  the  cornea.  Groenouw  found  partial 
atrophy  of  the  epithelium  of  the  pars  plana.  The  vitreous  contained 
round-cells  and  nbrillae,  especially  in  the  anterior  part,  and  to  some 
extent  in  front  of  the  optic  disc.  The  iris  was  infiltrated  and  also  the 
deeper  layers  of  the  peripheral  part  of  the  cornea.  Groenouw  con- 
siders iritis  as  secondary  to  the  cyclitis.  He  found  the  choroid,  retina, 
and  optic  nerve  healthy,  but  other  observers  have  found  them  affected 
(Knies,  Fuchs). 

Chronic  plastic  cyclitis  is  much  more  commonly  met  with  in  the 
pathological  laboratory.  Here  the  exudate  is  very  rich  in  fibrin  and  is 
gradually  organised  into  fibrous  tissue.  The  ultimate  result  is  phthisis 
bulbi,  the  picture  differing  in  no  respect  from  the  late  stages  of  non- 
suppurative  acute  plastic  cyclitis.  The  intermediate  stages  are  best 
seen  in  cases  of  pseudo-glioma,  where  the  difficulty  of  diagnosis  leads 
to  comparatively  early  enucleation. 

WARDROP.  — Essays  on  the  Morbid  Anatomy  of  the  Human  Eye,  Edinburgh.  1808. 
RUETE. — Lehrbuch,  Braunschweig,  1845.  STELLWAG  v.  CARION. — Lehrbuch,  Wien.  ARLT. 
— Die  Krankheiten  des  Auges,  ii,  Prag,  1853.  v.  GRAEFE. — A.  f.  O.,  ii,  2,  1856.  DE  WECKER. 
— In  G.-S.,  iv,  1876.  KNIES.— A.  f.  A.,  ix,  1880.  FUCHS.— A.  f.  O.,  xxx,  3,  1884. 
SCHWEIGGER. —  Handbuch,  5th  ed.,  Berlin,  1885.  SNELLEN,  JR.  —  Ophth.  Rev.,  xiii, 
1894.  RIDLEY. — R.  L.  O.  H.  Rep.,  xiv,  1895.  UHTHOFK  AND  AXENFELD. — A.  f.  A.,  xlii, 
1896.  GROENOUW. — K.  M.  f.  A.,  xxxviii,  1900.  BAAS. — Z.  f.  A.,  ix,  1903.  LEBER. — 
B.  d.  o.  G.,  1879.  v.  MICHEL. — IX  Internat.  Ophth.  Congress,  Utrecht,  1899.  TREACHER 
COLLINS. — Researches,  London,  1896. 


SYMPATHETIC  CYCLITIS 

The  ciliary  body  in  sympathetic  ophthalmia  usually  shows  traces  of 
chronic  inflammation.  The  exciting  eye  may  be  attacked  with  the 
ordinary  acute  cyclitis  as  the  result  of  the  injury.  In  other  cases  it 
enters  into  the  condition  of  a  subacute  or  chronic  irido-cyclitis.  In 
yet  another  group  of  cases  the  inflammatory  symptoms  are  minimal: 
there  is  no  keratitis  punctata,  and  only  slight  irritability,  manifested  by 
lacrymation  and  transient  ciliary  injection.  In  one  such  "  dangerous 
eye "  which  I  have  had  the  opportunity  of  examining,  there  were 
nodules  of  lymphocytes  in  the  iris  and  ciliary  body — a  condition  which 
is  not  uncommon  in  chronic  inflammation,  and  may  be  called  nodular 
irido-cyclitis  for  the  sake  of  distinction.  The  nodular  aggregations  are 
commoner  in  the  iris  and  choroid  than  in  the  ciliary  body ;  they  may 
contain  numerous  giant-cells,  as  well  as  epithelioid  cells,  so  that  the 
resemblance  to  tubercle  is  very  striking ;  this  occurs  more  frequently 
in  the  choroid  than  in  the  ciliary  body  or  iris.  The  observation  of 
giant-cell  systems  was  first  made  by  Krause  (1881),  and  has  since  been 
confirmed  by  Schirmer,  Axenfeld,  Pincus,  and  many  others.  The 
giant-cells  are  often  very  large,  and  have  many  nuclei,  which  are  usually 
arranged  irregularly,  but  may  assume  the  Langhans  type. 

23 


354  THE    PATHOLOGY   OF   THE    EYE 

The  conditions  found  in  the  ciliary  body  of  the  sympathising  eye  in 
the  cases  which  have  been  examined  are,  apart  from  the  injury, 
identical  with  those  in  the  exciting  eye.  Sympathetic  serous  cyclitis 
has  been  examined  in  one  case  only  (Grunert's  case,  Schirmer)  ; 
keratitis  punctata  and  infiltration  of  the  whole  uveal  tract  were  present. 
In  other  cases  nodular  deposits  of  lymphocytes,  with  or  without 
epithelioid  and  giant-cells,  have  been  observed. 

KRAUSE. — A.  f.  A.,  x,  1881.  SCHIRMER. — A.  f.  O.,  xxxviii,  4,  1892.  PINCUS. — A.  f.  O., 
xl,  4,  1894.  AXENFELD. — B.  d.  o.  G.,  1897.  *SCHIRMER. — In  G.-S.,  2nd  ed.,  1900. 


SYPHILIS 

In  syphilis  the  ciliary  body  may  be  diffusely  infiltrated  with  granula- 
tion tissue  and  surrounded  by  inflammatory  exudates.  This  occurs 
most  commonly  when  the  choroid  is  probably  the  primary  seat,  or  is 
at  least  most  affected  ;  the  latter  contained  giant-cell  systems  in  a  case 
reported  by  Fialho.  The  granulation  tissue  is  more  frequently  localised, 
and  undergoes  necrosis,  often  involving  the  iris,  cornea,  and  angle  of 
the  anterior  chamber,  as  well  as  breaking  through  the  sclerotic  and 
appearing  as  an  ulcer  upon  the  surface.  The  latter  may  have  a  typical 
"  wash-leather  "  slough.  I  have  reported  three  such  cases,  which  were 
remarkably  similar.  The  following  is  a  description  of  one  of  them  : 

The  ciliary  body  was  intensely  inflamed  and  congested,  the  blood- 
vessels being  dilated  and  packed  with  red  corpuscles.  The  ciliary  pro- 
cesses were  covered  with  leucocytes,  and  at  the  tips  the  pigment  layer 
of  epithelium  had  become  bleached.  The  origin  of  the  ciliary  muscle 
was  intact  above.  Behind,  the  whole  ciliary  body  was  detached  from 
the  sclera,  the  space  being  full  of  a  loose  pigmented  network,  which 
contained  albuminous  coagulum ;  the  detachment  extended  back  to  the 
equator,  posterior  to  which  the  choroid  was  in  situ.  Below,  the  ciliary 
body  was  largely  replaced  by  gummatous  infiltration,  a  few  layers  of 
muscle,  carrying  the  very  inflamed  processes,  alone  remaining 
(Fig.  257).  All  the  more  external  parts  had  become  absorbed  ;  the 
sclerotic  was  absorbed  here,  with  the  exception  of  a  strand  which  ran 
forward  to  the  centre  of  the  mass,  where  it  ended  in  a  necrotic  mass. 
Externally  the  gumma  opened  on  to  the  conjunctiva  as  an  ulcer,  the 
episcleral  tissues  being  necrosed.  The  conjunctiva  round  the  ulcer  formed 
a  swollen  fold,  the  epithelium  having  grown  in  along  the  under  surface 
for  a  considerable  distance  on  each  side.  The  conjunctival  stroma 
consisted  of  much-dilated  vessels  surrounded  by  closely  packed  round 
cells.  The  gumma  itself  was  almost  entirely  necrotic.  It  consisted  of 
masses  of  round-cells  with  fragments  of  partially  absorbed  sclerotic, 
etc.  There  were  no  giant-cells.  There  were  no  blood-vessels  in  the 
central  parts.  At  the  periphery  the  cells  stained  better,  and  showed  a 
zone  of  inflammatory  reaction.  On  the  inner  side  they  were  endothelial 
in  type,  the  smaller  round-cells  being  principally  distributed  around 
the  vessels.  In  front  round  inflammatory  cells  invaded  the  cornea, 
spreading  up  the  spaces  between  the  lamellae,  and  separating  these 
widely,  so  that  the  cornea  was  much  thickened.  A  small  portion  of 


THE    CILIARY    BODY 


355 


the  limbus  was  entirely  destroyed,  so  that  the  gumma  invaded  the 
angle  of  the  anterior  chamber.  The  vitreous  was  pervaded  with 
leucocytes,  mostly  aggregated  in  the  lower  part.  The  ciliary  pro- 
cesses were  pressed  inwards,  and  the  softening  of  the  sclerotic  had 
subsequently  allowed  it  to  be  forced  outwards  by  the  subciliary  and 
subchoroidal  exudate.  The  inflammation  had  travelled  outwards  in 
the  direction  of  the  lymph-  and  blood-streams,  probably  along  the 
course  of  the  anterior  ciliary  vessels. 

Whilst  there  have  been  several  clinical  cases  of  gumma  of  the 
ciliary  body  recorded,  very  few  have  been  examined  microscopically. 
The  early  cases  of  v.  Hippel,  Delafield,  Barbar,  Loring  and  Eno 
afford  little  more  than  topographical  details.  Alt  records  a  gumma 


FIG.  257. — GUMMA  OF  CILIARY  BODY. 
Morton  and  Parsons,  T.  Q.  S.,  xxii. 

which  was  confined  to  the  ciliary  body,  but  does  not  give  many 
histological  details.  Scherl's  case  was  much  farther  advanced,  and  is 
remarkable  in  that  the  lens  was  involved.  Ostwalt  and  Coppez  give 
bibliographies  of  cases  recorded  up  to  1896  and  1898  respectively.  The 
latter  describes  a  case  of  condyloma  of  the  ciliary  body  which  bears 
great  resemblance  to  the  case  recorded  above.  He  lays  much  stress 
upon  the  importance  of  distinguishing  between  the  earlier  secondary  and 
the  later  tertiary  manifestations.  It  is  open  to  question  whether  this 
is  possible  pathologically,  and  whether  it  is  of  any  importance  clinically, 
at  any  rate  in  the  case  of  the  ciliary  body.  Coppez  carefully  analyses 
previously  reported  cases  according  to  his  views,  and  supplies  useful 
abstracts  of  them.  Baas  reviews  the  whole  subject  of  syphilis  in  the 
eye,  and  Brixa  reports  a  gumma  of  the  ciliary  body,  with  much  loss  of 
tissue  and  widespread  syphilitic  changes  in  other  parts  of  the  eye.  It 


356  THE    PATHOLOGY   OF   THE    EYE 

is  noteworthy  that  in  most  of  the  cases  examined  microscopically 
giant-cells  were  absent.  This  accords  with  Baumgarten's  dictum  that 
"  in  pure  gummata  giant-cells,  especially  of  the  Langhans  type,  may 
be  entirely  absent."  He  regards  their  presence  as  an  indication  of  a 
mixed  infection  of  syphilis  and  tubercle.  A  more  recent  case  is  that  of 
Hanke  from  Professor  Fuchs's  clinic,  and  it  is  remarkably  similar  to 
the  one  recorded  above.  Fialho,  apropos  of  an  eye  from  the  same 
source  with  very  extensive  syphilitic  lesions  showing  giant-cells,  dis- 
cusses the  accuracy  of  Baumgarten's  conclusions. 

VON  HIPPEL.  — A.  f.  O.,  Bd.  xiii,  i,  1867.  DELAFIEI.D. — T.  Am.  O.  S.,  1871.  BARBAR. 
— Nagel's  Jahresbericht,  1873.  LORING  AND  ENO. — T.  Am.  O.  S.,  1874.  ALT. — A.  f.  A., 
vi,  1877.  SCHERL. — A.  f.  A.,  xxv,  1892.  OSTWALT. — Rev.  gen.  d'Opht.,  1896.  COPPEZ. 
—A.  d'O.,  xviii,  1898.  BAAS.— A.  f.  O.,  xlv,  3,  1898.  BRIXA. — A.  f.  O.,  xlviii,  i,  1899. 
BAUMGARTEN. — Virchow's  Archiv,  cxi,  1888.  JULER. — Ophth.  Rev.,  xvii,  1898.  HANKE. — 
A.  f.  O.,  xlviii,  2,  1899.  FIALHO. — A.  f.  O.,  lii,  3,  1901.  PARSONS. — T.  O.  S.,  xxii,  1902; 
R.  L.  O.  H.  Rep.,  xv,  3,  1903.  *TOOKE. — A.  f.  A.,  xli,  Beilageheft,  1903.  *EWETZKY. — 
Ueber  d.  Syphilom  d.  Ciliarkorpers,  Berlin,  1904. 


Tubercle  of  the  ciliary  body  is  generally  an  extension  of  the  disease 
from  the  iris  or  choroid.  It  is  not  improbable,  however,  that  it  com- 
mences more  frequently  in  this  situation  than  published  records  would 
lead  one  to  suppose,  a  view  which  is  supported  by  the  susceptibility  of 
the  ciliary  body  to  other  granulomatous  affections.  The  microscopical 
characteristics  do  not  differ  from  those  elsewhere  in  the  uveal  tract, 
and  do  not  demand  special  description.  The  connective  tissue  is  first 
involved,  the  muscle  later  and  in  less  degree.  Large  masses  are  often 
formed,  limited  internally  by  the  more  or  less  fragmentary  retinal 
epithelium,  externally  by  the  ciliary  muscle.  Perforation  of  the  globe 
is  especially  frequent  (Lagrange).  Diagnosis  rests  upon  the  presence 
of  caseation  and  the  demonstration  of  tubercle  bacilli,  either  by  staining 
or  inoculation. 


LEPROSY 

The  ciliary  body  is  a  favourite  site  for  leprosy,  which  is  often 
primary  here  as  regards  the  eye.  As  usual  the  bacilli  are  found  near 
the  blood-vessels,  but  less  so  than  in  the  iris  (Lie),  in  the  lymph-spaces 
around  the  muscle-fibres,  but  not  in  them,  and  along  the  nerves.  They 
may  also  be  found  in  small  numbers  in  the  pigment-cells.  The  muscle- 
fibres  contain  the  typical  lepra  pigment  granules,  staining  like  the 
bacilli,  but  being  less  acid-fast.  The  granulation  tissue  is  generally 
developed  only  moderately,  but  may  involve  and  destroy  the  whole 
ciliary  body  (Franke  and  Delbanco). 

(For  BIBLIOGRAPHY,  see  "  Lids,"  "  Cornea.") 


THE    CILIARY    BODY  357 

DEGENERATIONS 

SENILE  DEGENERATION 

Senile  degenerative  changes  in  the  ciliary  body  are  often  well 
marked,  and  have  received  minute  attention  from  Kerschbaumer. 

The  ciliary  processes  are  longer  and  more  branched,  and  the 
anterior  parts  are  often  swollen,  so  that  the  iris  is  pressed  forwards  at 
the  periphery  ;  this  may  be  a  factor  in  the  causation  of  glaucoma. 
They  also  encroach  upon  the  posterior  chamber.  The  non-pigmented 
epithelium  often  shows  hyperplasia,  the  cells  proliferating  by  karyo- 
kinesis  and  forming  excrescences  (Kuhnt).  The  cells  become  convex 
towards  the  vitreous,  and  neighbouring  excrescences  form  a  festoon-like 
arrangement,  often  with  a  central  lumen  ;  in  this  manner  large  cystic 
spaces  may  be  produced  (v.  p.  358).  The  pigmented  epithelium  some- 
times participates  in  the  proliferation  (Kuhnt,  Kerschbaumer). 

The  basal  hyaline  membrane  increases  in  thickness  from  the  age  of 
forty  onwards.  The  outer  part  loses  its  hyaline  character  and  becomes 
granular.  The  fibres  of  the  inner  network  become  thickened. 

The  connective  tissue  is  thickened  throughout,  and  often  becomes 
hyaline.  The  vessels  show  signs  of  sclerosis,  the  walls  becoming  thick, 
fibrillated,  or  hyaline,  and  the  lumina  contracted. 

The  muscle  fibres  degenerate,  many  nuclei  disappearing  and  the 
bundles  becoming  thin.  The  intermuscular  spaces  contain  hyper- 
trophied  connective  tissue,  fluid,  or  granular  coagula. 

KUHNT. — K.  M.  f.  A.,  xix,  1881.     KERSCHBAUMER. — A.  f.  O.,  xxxiv,  4,  1888. 

ATROPHY 

Atrophic  changes  in  the  ciliary  body  are  common  after  cyclitis  and 
in  old  glaucomatous  eyes.  When  moderately  pronounced,  there  is 
marked  connective-tissue  hyperplasia,  with  atrophy  of  the  higher 
tissues.  The  ciliary  body  is  pervaded  with  thick  bands  of  fibrillar  or 
hyaline  connective  tissue,  the  muscle  bundles  are  thin,  and  have  lost 
many  of  their  nuclei,  though  complete  atrophy  is  rare  (Figs.  255,  258). 
The  blood-vessels  are  sclerosed.  The  ciliary  processes  are  thin, 
shrunken,  and  reduced  in  number,  though  some  are  often  drawn  out 
into  the  vitreous  and  are  longer  than  normal.  The  whole  ciliary  body 
is  flattened  and  much  reduced  in  size. 

These  changes  are  accompanied  by  a  diminished  secretory  activity, 
so  that  a  previously  increased  intra-ocular  tension  may  be  reduced  far 
below  normal. 

CALCIFICATION  AND  OSSIFICATION 

Calcification  and  ossification  of  the  ciliary  body  itself  is  rare,  and  is 
nearly  always  a  sequel  of  ossification  in  the  choroid.  The  process  is 


358  THE    PATHOLOGY   OF   THE   EYE 

similar,  and  will  receive  detailed  description  in  treating  of  the  choroid. 
The  same  changes  more  frequently  occur  in  cyclitic  membranes  and 
deposits,  and  have  been  described  elsewhere  (v.  p.  346). 


CYSTS 

Kuhnt  (1881)  first  described  cysts  of  the  ciliary  body  as  a  senile 
change.  They  occur  principally  in  the  pars  plana,  near  the  ora  serrata, 
and  are  formed  by  separation  of  the  non-pigmented  from  the  pigmented 
layer  of  cells.  They  are  therefore  similar  to  those  cysts  of  the  iris 
which  are  caused  by  separation  of  the  two  layers  of  pigmented  retinal 
epithelium.  Others  are  formed  by  separation  of  the  pigment  layer 
from  the  underlying  ciliary  body.  Larger  cysts  arise  by  confluence  of 
smaller  ones.  The  phenomenon  is  due  to  abnormalities  in  the 
transudation  of  lymph,  and  is  always  the  result  of  degenerative,  and 
often  of  inflammatory,  conditions.  This  is  shown  by  the  atrophic 
condition  of  the  ciliary  body  in  the  cases. 

Cystic  spaces  produced  by  "  detachment  of  the  pars  ciliaris  retinae 
from  the  subjacent  pigment  layer"  were  also  noticed  by  Brailey  (1882). 
When  associated  with  cyclitis  they  contained  corpuscular  elements. 

The  largest  cysts  of  the  ciliary  body  were  described  by  Greeff,  and 
resulted  from  atrophy  of  the  ciliary  body  after  irido-cyclitis  following 
cataract  extraction  for  a  traumatic  cataract.  The  eye  was  removed 
seven  years  after  the  operation,  and  was  in  a  condition  of  phthisis  bulbi 
with  complete  detachment  of  the  retina.  The  cysts  were  observed 
ophthalmoscopically.  Behind  the  cornea  were  two  cysts,  the  outer 
7*5  mm.  broad  and  6*5  min.  high,  the  inner  5  mm.  broad  and  8  mm. 
high.  The  thin  walls  were  pigmented  and  enclosed  a  clear  fluid.  The 
ciliary  body  was  completely  atrophic,  the  processes  being  pressed  aside 
and  appearing  as  dark  pigmented  bands.  The  epithelium  of  the  pars 
ciliaris  retinas  was  no  longer  recognisable.  The  cyst-wall  was  lined  by 
a  single  layer  of  flattened  "  endothelial "  cells  ;  the  atrophic  pigmented 
uveal  tissue  formed  the  outer  part  of  the  wall. 

Greeff  explains  these  cysts  on  the  theory  of  retained  secretion  of 
Treacher  Collins's  glands.  After  the  extraction  of  the  traumatic 
cataract  a  slow  irido-cyclitis  led  to  adhesion  of  some  of  the  ciliary 
processes  to  each  other  and  to  the  ciliary  body.  Closed  spaces  were 
thus  formed,  into  which  more  and  more  serous  fluid  was  poured.  As 
the  cysts  grew  the  cylindrical  epithelium  became  flattened,  so  that  a 
single  layer  of  flattened  cells  resulted. 

Treacher  Collins  mentions  an  eye  with  cyclitis  which  showed  cysts 
due  to  the  distension  of  the  glands.  He  states  that  such  cysts  "  would 
differ  from  those  due  to  detachment  of  the  pars  ciliaris  retinae  from  the 
pigment  epithelium  in  being  bounded  entirely  by  pigment-cells.0 

KUHNT.— K.  M.  f.  A.,  xix,  1881.  BRAILEY. — R.  L.  O.  H.  Rep.,  x,  1882.  KERSCHBAUMER. 
— A.  f.  O.,  xxxiv,  4,  1888.  GREEFF. — A.  f.  A.,  xxv,  1892.  TREACHER  COLLINS. — Researches, 
London,  1896. 


THE    CILIARY   BODY 


359 


TUMOURS 

EPITHELIAL  HYPERPLASIA 

We  have  seen  that  epithelial  hyperplasia  occurs  in  old  age  (Kuhnt, 
Kerschbaumer),  with  the  formation  of  small  festoon-like  thickenings, 
and  also  in  cyclitis  (Alt,  Treacher  Collins),  with  the  formation  of  non- 
pigmented  and  pigmented  bands  and  tubes  or  tumour-like  thickenings. 
Kruckmann  describes  small  nodules  of  granulation  tissue  covered  by 
epithelium,  which  sprout  out  into  the  vitreous  in  cyclitic  conditions. 


FIG.  258. — EPITHELIAL  HYPERPLASIA  OF  CILIARY  BODY,      x  55. 
Note  the  fibrous  degeneration  of  the  ciliary  body  itself.     (R.  L.  O.  H.  Rep.,  xv.) 

The  granulation  tissue  shrinks  later,  so  that  spaces  covered  with 
epithelium  are  formed  in  the  scar  tissue.  Only  rarely  does  the  epithe- 
lium appear  to  invade  the  preformed  tissues,  and  these  are  then  found 
to  be  in  a  sclerosed  cicatricial  condition. 

Hanke  described  an  "  epithelioma "  of  the  ciliary  processes  in  a 
woman  aet.  65.  The  new  growth  commenced  under  the  epithelium, 
was  reniform  in  shape,  with  the  hilum  directed  towards  the  vitreous. 
The  two  layers  of  retinal  epithelium  were  continued  over  the  tumour, 
the  outer  layer  being  less  pigmented  over  the  convexity.  This  layer 
remained  one  cell  thick,  whilst  the  inner,  non-pigmented  layer  formed 
a  network  of  bands  and  nests  with  spaces  between  them. 

Some  of  Alt's  cases  (v.  p.  360)  undoubtedly  belong  to  the  same 
category. 


360  THE    PATHOLOGY    OF   THE    EYE 

I  have  met  with  a  growth  in  every  respect  resembling  Hanke's, 
occurring  in  a  man  set.  65.  On  one  ciliary  process  below  was  a  globular 
mass  on  the  anterior  surface,  with  its  long  axis  in  the  direction  of  the 
process.  It  was  about  i  mm.  long  by  0*75  mm.  wide.  The  non- 
pigmented  retinal  epithelium  could  be  traced  on  to  its  surface,  whilst 
the  pigmented  epithelium  was  continued  under  it,  though  the  cells  soon 
lost  their  pigment,  which  was  also  absent  or  scanty  on  many  of  the  pro- 
cesses. The  main  mass  of  the  swelling  consisted  of  irregular  groups  of 
cells  resembling  the  non-pigmented  epithelium,  lying  in  a  hyaline 
matrix,  with  numerous  irregular  spaces.  The  nuclei  stained  faintly, 
were  round  or  oval ;  the  outlines  of  the  cells  were  indistinct.  No 
tubular  arrangement  of  the  cells  could  be  demonstrated,  though  the 
general  disposition  was  suggestive  of  such  an  arrangement. 

It  is  clear,  I  think,  that  these  cells  are  due  to  the  proliferation  of  the 
non-pigmented  or  inner  layer  of  the  retinal  epithelium,  and  that  the 
proliferation  has  taken  place  into  the  vitreous  body,  the  underlying 
ciliary  process  showing  the  same  condition  as  the  others.  There  was 
no  evidence  of  inflammation,  such  as  infiltration  with  leucocytes,  either 
in  or  around  the  mass. 

Schlipp  reported  an  epithelial  tumour  of  the  ciliary  body  in  the 
shrunken  globe  of  a  girl  set.  10.  The  posterior  part  of  the  globe  was 
almost  filled  with  pigmented  and  non-pigmented  epithelium,  often 
arranged  in  bands.  The  cells  were  large  and  polygonal ;  many  of  the 
nuclei  were  much  swollen,  and  the  cytoplasm  contained  fatty  and  hya- 
line globules.  There  were  no  giant-cells  orcaseation.  The  bands  were 
separated  by  connective  tissue  with  scant  blood-supply  and  bone. 

KRUCKMANN. — IX  Internal.  Ophth.  Congress,  Utrecht,  1859.     HANKE. — A.  f.  O  ,  xlvii, 
PARSONS. — R.  L.  O.  H.  Rep.,  xv,  4,  1503.     SCHLIPP. — A.  f.  O.,  xlviii,  i£cg. 


ADENOMA 

Several  epithelial  growths  have  been  described  as  adenomata.  Fuchs 
described  a  nodule  with  adenoma-like  structure  between  two  folds  of  a 
ciliary  process  in  a  case  of  chronic  uveitis  with  glaucoma.  It  occurred 
in  a  woman  set.  70.  The  cellular  bands  lay  embedded  in  a  homogeneous 
mass,  and  the  nodule  received  a  blood-vessel  from  the  ciliary  body,  the 
walls  of  which  were  pigmented.  It  was  probably  a  simple  epithelial 
hyperplasia  (v.  p.  359). 

Pergens  described  an  adenoma  0*75  mm.  long  by  0*25  mm.  broad 
in  the  ciliary  body  of  a  man  set.  56.  The  eye  had  been  injured  by  a 
piece  of  iron  four  years  before,  and  had  had  two  iridectomies.  The 
growth  consisted  of  tubules  of  epithelium  lying  in  a  gelatinous  material. 

Alt  has  reported  five  cases  of  adenoma  of  the  ciliary  body,  mostly  in 
the  eyes  of  old  people.  The  growths  were  generally  microscopic  in  size, 
and  were  in  all  cases  found  incidentally  in  the  course  of  routine  exa- 
mination. Two  eyes  were  removed  post  mortem  from  a  case  of  croupous 
pneumonia  ;  the  third  was  enucleated  for  sarcoma  of  the  conjunctiva  ; 
the  fourth  was  a  traumatic  suppurative  panophthalmitis  ;  the  fifth  was 


THE    CILIARY    BODY  361 

removed  on  account  of  an  injury.  Most  of  these  belong  to  the  type  of 
epithelial  hyperplasias. 

In  the  typical  cases  the  non-pigmented  epithelium  bursts  through 
the  pigmented  layer,  and  grows  in  bands  and  tubules  in  an  amorphous 
or  gelatinous  matrix;  the  cells  often  show  colloid  degeneration.  The 
surrounding  tissues  appear  to  be  passive,  and  show  no  reaction. 

The  published  cases  of  adenoma  are  too  few  and  too  anomalous  to 
permit  of  dogmatic  statements.  The  diagnosis  of  an  adenoma  pre- 
supposes the  existence  of  glands,  and  this  question  must  still  be  regarded 
as  sub  judice.  On  the  other  hand,  looked  at  from  the  point  of  view  of 
inflammatory  or  degenerative  hyperplasia  (Emmanuel,  Kriickmann), 
there  is  no  such  theoretical  foundation,  whilst  it  must  at  the  same  time 
be  admitted  that  simple  hyperplasia  does  not  usually  assume  such  an 
atypical  complexity  of  structure. 

FUCHS. — A.  f.  O.,  xxix,  4,  1883.  PERGENS. — A.  f.  A.,  xxxii,  1896.  ALT. — Amer.  Jl.  of 
Ophth.,  xv,  1898.  TREACHER  COLLINS.  —  Researches,  London,  1896.  EMMANUEL. — 
Virchow's  Arch.,  clxi,  1900.  KRUCKMANN. — IX  Internal.  Congress,  Utrecht,  1899. 

CARCINOMA 

Primary  carcinomata  of  the  ciliary  body  have  been  described  by 
v.  Michel,  Treacher  Collins,  and  Badal  and  Lagrange. 

v.  Michel  (1878)  described  an  "  endothelial  and  epithelial  cancer  of 


FIG.  259. — MELANOTIC  CARCINOMA  (?)  OF  CILIARY  BODY,      x  300. 
From  Treacher  Collins.     Bleached  section.     (T.  O.  S.,  xi.) 

the  ciliary  body."     He  has  since  arrived  at  the  conclusion  that  it  was  a 
pure  endothelial  growth  (Emmanuel)  (v.  p.  363). 

Treacher  Collins  (1891)  described  an  epithelial  growth  in  a  girl  of 


362 


THE    PATHOLOGY   OF   THE    EYE 


nineteen,  and  another  in  a  woman  of  sixty-three,  who  twenty-seven  years 
previously  had  had  a  severe  blow  on  the  eye  from  a  fist,  and  two  years 
after  had  found  that  it  was  blind.  The  growth  was  partially  pigmented, 
sprang  from  the  ciliary  processes,  and  invaded  the  ciliary  muscle  and 
root  of  the  iris.  It  had  epithelial  tubules,  and  had  partially  undergone 
colloid  degeneration  (Fig.  259).  It  was  regarded  as  a  primary  melanotic 
glandular  carcinoma. 

Badal  and  Lagrange  (1892)  described  a  primary  carcinoma  of  the 
ciliary  body  in  a  boy  set.  8.  The  eye  had  been  blind  three  years,  and 
had  an  intercalary  staphyloma.  There  were  two  white  nodules  close 
together  in  the  ciliary  region,  and  these  were  composed  of  (i)  regular 
tubules  with  a  central  lumen,  lined  by  a  single  layer  of  cylindrical 
epithelium;  (2)  similar  tubules  filled  with  proliferating  epithelial  cells; 


FIG.  260.— CARCINOMA  OF  CILIARY  BODY,      x  300. 
Snell  and  Treacher  Collins,  T.  O.  S.,  xix. 

(3)  collections  of  atypical  and  deformed  epithelial  cells  grouped  and 
separated  by  thin  strands  of  connective  tissue. 

Treacher  Collins  (1893)  described  another  tumour  of  the  ciliary 
body  with  glandular  structure,  in  a  woman  set.  28.  Vision  had  been 
failing  for  six  months.  The  anterior  part  of  the  tumour  was  deeply  pig- 
mented, the  posterior  part  devoid  of  pigment.  Microscopically  the 
cells  composing  the  central  portions  of  the  growth  appeared  very 
degenerate  ;  they  were  much  swollen  and  their  outlines  were  ill  defined. 
The  more  peripheral  parts  were  less  degenerated  ;  the  cells  here  were 
of  epithelial  character,  and  arranged  in  a  way  suggestive  of  a  glandular 
structure. 

The  very  extensive  carcinoma-like  intra-ocular  growth  reported  by 
Snell  and  described  by  Treacher  Collins  resembles  those  already 
mentioned  (Fig.  260),  but  its  site  of  origin  is  impossible  to  determine. 


THE   CILIARY   BODY  363 

The  same  criticisms  relative  to  adenomata  apply  with  equal  force  to 
the  primary  carcinomata  of  the  ciliary  body. 

Secondary  carcinoma  of  the  ciliary  body  is  usually  by  continuity 
from  the  choroid,  and  is  very  rare.  Two  cases  are  on  record  (Ewing, 
Abelsdorff)  ;  in  each  case  metastatic  carcinoma  of  the  choroid  followed 
a  primary  growth  in  the  breast.  In  both  cases  the  ciliary  muscle  fibres 
were  pushed  apart  by  nests  of  epithelial  cells.  The  ciliary  processes, 
especially  the  anterior  ones  (Abelsdorff),  were  also  involved,  but  only 
to  a  small  extent.  In  AbelsdorfFs  case  the  root  of  the  iris  was  also 
invaded. 

TREACHER  COLLINS. — T.  O.  S.,  xi,  1891  ;  xiv,  1894. ;  Researches,  London,  1896. 
BADAL  AND  LAGRANGE.— A.  d'O.,  xii,  1892;  LAGRANGE. — Tumeurs  de  1'CEil,  i,  Paris,  1901. 
EWING. — A.  f.  O.,  xxxvi,  i,  1890.  ABELSDORFF. — A.  f.  A.,  xxxiii,  1896.  SNELL. — T.  O.  S., 
xix,  1899. 

GLIOMA 

Emmanuel  described  a  case  of  primary  glioma  of  the  ciliary  body. 
The  patient  was  a  child  set.  5^.  The  pupil  had  been  elongated  down- 
wards since  birth  ;  there  was  a  large  ciliary  staphyloma  around  the 
cornea.  In  the  staphyloma  was  a  growth  10  mm.  long  by  6  mm. 
broad.  The  tumour  started  in  the  pars  ciliaris  retinae,  and  consisted  of 
bands  of  cells  arranged  in  folds  and  networks  ;  rosettes  were  also 
present  in  large  numbers.  Emmanuel  regards  Badal  and  Lagrange's 
case  as  a  glioma.  The  term  neuro-epithelioma  is  perhaps  the  least 
objectionable  name  for  such  neoplasms.  In  any  case  they  must  not  be 
regarded  as  gliomata  in  the  sense  of  being  derived  from  or  containing 
neuroglia. 

Hirschberg  and  Happe  reported  a  case  of  glioma  endophytum 
starting  in  the  pars  ciliaris  retinas  and  the  immediate  neighbourhood. 

Helfreich  described  a  gliomatous  proliferation  in  a  microphthalmic 
eye,  containing  folded  bands,  which  sprang  from  the  ciliary  processes. 

Secondary  glioma  usually  attacks  the  ciliary  body  from  the  choroid, 
but  may  also  do  so  from  the  supra-choroida)  space  or  from  the  inner 
surface.  In  late  stages  the  ciliary  body  is  replaced  by  the  growth,  its 
contour  only  being  marked  out  by  a  line  of  pigment  ;  the  ciliary  pro- 
cesses succumb  last,  and  finally  no  trace  of  the  ciliary  body  is  left 
(Wintersteiner) . 

EMMANUEL. — Virchow's  Archiv,  clxi,  1900.  HIRSCHBERG  AND  HAPPE. — A.  f.  O.,  xvi, 
i,  1870.  HELFREICH. — A.  f.  O.,  xxi,  2,  1875.  WINTERSTEINER. — Das  Neuroepithelioma 
Retinae,  Leipzig  and  Wien,  1897. 


ENDOTHELIOMA 

The  tumour  first  described  by  v.  Michel  (1878)  as  an  "  endothelial 
and  epithelial  cancer  of  the  ciliary  body  "  has  since  been  regarded  by 
the  author  as  of  pure  endothelial  origin  (Emmanuel).  It  occurred  in  a 
woman,  set.  41,  who  had  always  had  good  health  ;  the  eye  was  removed 
for  supposed  sarcoma  of  the  iris  and  ciliary  body.  The  tumour  con- 


364  THE    PATHOLOGY    OF   THE    EYE 

sisted  of  a  fine  network  of  connective  tissue,  carrying  a  few  vessels. 
Cylindrical  cells  were  arranged  like  a  pallisade  upon  both  sides  of  the 
connective  tissue,  and  bounded  narrow  spaces.  Hence  the  appearance 
of  a  tubular  gland  was  simulated.  Elsewhere  there  were  large  multi- 
nucleated  cells  with  branching  processes ;  these  might  well  have 
originated  in  endothelial  cells,  but  could  scarcely  be  derived  from 
cylindrical  epithelium.  The  tumour  showed  some  slight  tendency  to 
invade  the  normal  tissues,  but  grew  mostly  towards  the  vitreous. 

Another  endothelioma  of  the  ciliary  body,  partially  pigmented,  has 
been  described  by  Schleich  (1880).  Large,  closely  packed,  non- 
pigmented,  polygonal  cells  surrounded  capillary  vessels,  which  pos- 
sessed no  definite  walls  of  their  own,  and  which  were  derived  from  the 
ciliary  vessels.  Between  the  epithelioid  cells  were  large  round  cells 
filled  with  dark  granules  of  uveal  pigment,  and  a  smaller  number  of 
small  branching  and  spindle-shaped  cells  with  lighter  pigment, 
resembling  the  normal  chromatophores.  At  a  fairly  uniform  distance 
from  the  vessels  were  spaces  filled  with  hyaline  material.  Schleich 
regarded  the  tumour  as  derived  from  endothelial  cells  at  the  anterior 
part  of  the  ciliary  body,  near  the  angle  of  the  anterior  chamber.  From 
the  description,  the  growth  might  be  looked  upon  as  a  perithelioma. 

Emmanuel  regarded  Groenouw's  case  of  "  unpigmented  alveolar 
flat  sarcoma  "  of  the  ciliary  body  as  a  case  of  endothelioma  (v.  p.  372). 

It  will  be  seen  that  it  is  impossible  to  arrive  at  any  definite  conclu- 
sion as  to  the  true  nature  of  these  rare  growths.  The  name  under 
which  they  are  described  is  often  the  offspring  of  the  author's  precon- 
ceived ideas ;  and  in  most  cases  the  actual  description  bears  obvious 
traces  of  the  same  unconscious  influence. 

v.  MICHEL. — A.  f.  O.,  xxiv,  i,  1878.  SCHLEICH. — Mittheilungen  aus  der  ophth.  Klinik 
zu  Tubingen,  i,  1880. 


MYOMA,  MYOSARCOMA 

A  small  number  of  tumours  of  the  ciliary  body  have  been  described 
as  myomata  or  myosarcomata.  The  difficulties  of  substantiating  this 
diagnosis  are  very  great,  and  are  considered  by  Mitvalski  to  be 
insuperable.  The  presence  of  unstriped  muscle-fibres  normally  in  this 
situation  may  easily  lead  to  confusion  in  the  early  stages  of  a  new 
growth.  Moreover,  young  muscle  cells  have  not  such  a  characteristic 
rod-shaped  nucleus  as  the  adult  cell,  but  resemble  much  more  nearly 
the  branching  embryonic  connective-tissue  cells  which  are  found  in 
spindle-celled  sarcomata.  Per  contra,  large  sarcomatous  spindle  cells 
may  have  rod-shaped  nuclei,  rounded  at  the  ends,  and  often  somewhat 
bent,  exactly  like  muscle  cells.  No  trustworthy  differential  stain  has 
yet  been  found,  though  there  are  indications  that  such  a  stain  will 
probably  be  devised. 

Myomata  have  been  described  by  Iwanoff  (1867),  Solomon  (1882), 
Mules  (1888),  Deutschmann  (1890),  Lange  (1890),  and  Lagrange.  In 
all  cases  there  has  been  doubt  as  to  the  diagnosis,  which  has  lain 
between  myoma  and  spindle-celled  sarcoma,  and  in  most  cases  those 


THE   CILIARY   BODY 


365 


who  have  seen  the  actual  preparations  have  failed  to  agree.  Under 
these  circumstances  it  seems  best  to  refer  readers  to  the  original  com- 
munications for  further  details. 

hvAXOFF. — In  G.-S.,  iv,  pp.  6  and  8,  1876.  SOLOMON. — T.  O.  S.,  ii,  1882.  MULES. — 
T.  O.  S.,  viii,  1888.  DEUTSCHMANN. — B.  z.  A.,  i,  1890.  LANGE. — A.  i.  O.,  xxxvi,  3,  1890. 
LAGKANGE. — Tumeurs  de  1'CEtl,  i,  Paris,  1901.  MITVALSKI. — A.  f.  A.,  xxviii,  1894. 


SARCOMA 

Primary  sarcoma  of  the  ciliary  body  is  a  rare  disease,  though  the  fifty 
or  sixty  recorded  cases  give  little  idea  of  its  relative  frequency.  It 
often  manifests  itself  first  by  localised  injection  or  pigmentation  of  the 


FIG.  261. — SARCOMA  OF  THE  CILIARY  BODY,      x  3. 

From  a  woman  set.  50.  Horizontal  section.  Melanotic  spindle-celled  sarcoma 
of  ciliary  body  on  outer  side,  with  large  central  degenerated  area.  Simple  detach- 
ment of  retina  on  inner  side.  The  growth  is  commencing  to  invade  the  a.  c.,  and 
has  already  extended  along  the  anterior  perforating  vessels,  forming  several 
episcleral  nodules. 

ciliary  region,  or  by  growing  forward  into  the  anterior  chamber.  In 
the  latter  event  it  usually  pushes  the  iris  away  from  its  peripheral 
attachment,  and  produces  an  irido-dialysis  (Fig.  262).  The  cause  of 
this  symptom  may  be  recognised  by  the  pigmentation  of  the  growth,  or 
by  the  observation  of  vessels  upon  its  surface.  The  course  of  the 
disease  runs  through  the  four  stages  characteristic  of  all  intra-ocular 
growths,  viz.  (i)  localised  growth  :  this  differs  from  choroidal  sarcoma 
in  that  detachment  of  the  retina  does  not  occur,  or  occurs  late,  owing 
to  the  firmer  union  of  the  pars  ciliaris  retinae  and  the  region  of  the  ora 
serrata  to  the  underlying  uveal  tract  ;  (2)  increased  tension  :  this  is  said 


366 


THE   PATHOLOGY    OF   THE    EYE 


to  occur  later  in  ciliary  sarcoma  than  in  that  of  the  choroid  (Devereux 
Marshall)  ;  (3)  extra-ocular  extension :  this  occurs  relatively  early, 
owing  to  the  proximity  of  the  anterior  perforating  vessels,  and  to  the 
prevalent  direction  of  the  lymph-stream  outwards  ;  (4)  general  metas- 
tasis :  this  differs  in  no  respect  from  that  of  choroidal  sarcoma. 

It  is  often  impossible,  both  clinically  and  pathologically,  to  dis- 
tinguish between  peripheral  choroidal  and  primary  ciliary  sarcomata. 

Fuchs  (1882)  found  22  cases  of  sarcoma  of  the  ciliary  body  amongst 
259  of  the  uveal  tract  (9  per  cent.) ;  of  these  2  were  non-pigmented. 
In  situation,  6  were  out,  4  in,  2  up,  4  down,  6  unknown.  Out  of  8 
cases  in  which  the  point  could  be  determined,  4  arose  from  the  outer 
layers,  2  from  these  or  from  the  ligamentum  pectinatum,  i  from  the 


FIG.  262. — SARCOMA  OF  CILIARY  BODY  INVADING  ANTERIOR  CHAMBER,      x  3. 

From  a  man  set.  68.     Melanotic  spindle-celled  sarcoma  of  ciliary  body,  grow- 
n  z  forwards  into  the  anterior  chamber.     Note  the  subluxation  of  the  lens. 


ciliary  muscle,  and  i  from  the  ciliary  processes ;  6  were  round-celled, 
7  spindle-celled,  3  mixed  round-  and  spindle-celled ;  i  was  a  myosar- 
coma,  i  an  endothelial  sarcoma,  and  4  were  unknown. 

Mules  (1888)  collected  27  cases,  details  of  which  are  tabulated  in 
his  article. 

Lawford  and  Treacher  Collins  (1890)  found  6  cases  in  103  cases  of 
sarcoma  of  the  uveal  tract  examined  at  Moorfields :  all  were  pig- 
mented ;  2  were  spindle-celled,  i  large  polygonal-celled,  3  mixed 
round-  and  spindle-celled. 

Kerschbaumer  (1900)  found  8  cases  in  67  of  sarcoma  of  the  uveal 
tract,  chiefly  from  the  Leipzig  clinic.  Of  these  most  were  spindle- 
celled  ;  these  were  of  relatively  slow  growth,  showing  fewer  mitoses  and 


THE    CILIARY    BODY  367 

multinucleated  cells,  and  appeared  to  be  relatively  benign ;  3  were 
pigmented,  3  were  leuco-sarcomata  with  hsematogenous  pigmentation, 
and  2  were  pure  leuco-sarcomata. 

Groenouw  (1898)  collected  50  cases  from  the  literature,  including 
the  so-called  myomata  and  myosarcomata.  Of  these,  5  were  leuco- 
sarcomata,  45  were  melanotic ;  this  agrees  fairly  with  Fuchs's  results 
for  the  whole  uveal  tract,  in  which  12  per  cent,  were  non-pigmented. 
Lawford  and  Collins  found  6  per  cent,  non-pigmented  for  the  whole  uveal 
tract,  so  that  a  comparison  of  this  result  with  that  of  Groenouw  for  the 
ciliary  body  only  (10  per  cent.)  supports  Fuchs's  view  that  leuco-sarco- 
mata are  commoner  in  the  anterior  portion  of  the  uveal  tract  than  in 
the  posterior.  The  inclusion  of  the  myosarcomata  and  of  an  endothe- 
lioma  (alveolar  sarcoma)  must  be  borne  in  mind. 

Of  30  cases,  Groenouw  found  7  round-celled,  13  spindle-celled,  and 
10  mixed-celled  ;  this  is  opposed  to  Fuchs's  rule  that  round-celled 
sarcomata  are  commoner  in  the  anterior,  spindle-  and  mixed-celled  in 
the  posterior  part  of  the  eye. 

The  average  age  for  the  round-celled  type  was  35,  for  the  spindle- 
celled  and  for  the  mixed-celled  44,  as  opposed  to  38,  45,  and  49  for  the 
whole  tract  (Fuchs).  The  average  duration  of  the  growths  at  the  time 
of  operation  was  7-3-,  13  £,  and  n£  months  respectively,  as  opposed  to 
i8£,  30,  and  34  months  for  the  whole  tract  (Fuchs).  This  shows  that 
ciliary  sarcomata  are  operated  upon  at  an  earlier  stage  ;  it  further 
agrees  with  Kerschbaumer's  later  result  for  a  different  set  of  cases  that 
round-celled  are  more  rapid  in  growth  than  spindle-celled. 

The  average  age  of  patients  with  leuco-sarcomata  of  the  ciliary  body 
was  32  (10  to  48),  with  melanotic  44  (10  to  74),  as  compared  with  30 
and  46  respectively  for  the  whole  tract  (Fuchs).  Out  of  5  non- 
pigmented  and  out  of  44  pigmented  i  was  ten  years  old  in  each  case  ; 
as  far  as  percentages  are  of  any  value  at  all  for  such  small  numbers, 
this  agrees  with  Fuchs's  estimates  for  the  whole  tract,  viz.  20  per 
cent,  and  i^  per  cent,  respectively. 

The  occurrence  in  consecutive  decades  was  as  follows  : 

Age.  Ciliary  body.  Uveal  tract  (Fuchs). 

I  —  IO  2  ...  II 

II — 20  ...  5  ...  l6 

21—30  ...      5  19 

31—40  9  43 

41—50  ii  55 

5i—6o  7  55 

61 — 70  ...  25 

71 — §0  ...  2  ...  10 

49  234 

As  regards  sex,  21  men  and  29  women  had  ciliary  sarcomata,  137 
men  and  116  women  sarcomata  of  the  uveal  tract  (Fuchs). 

The  side  affected  was — right,  23  ciliary  body  and  108  uveal  tract ; 
left,  24  and  101  ;  both,  i  and  5. 


368 


THE    PATHOLOGY    OF   THE    EYE 


FIG.  263. — SARCOMA  OF  CILIARY  BODY  INVADING  ANTERIOR  CHAMBER,      x   10. 
From  the  same   specimen  as  Fig.   262.      The  iris   is   seen  embedded   in    the 
growth;  the  pupillary  edge  with  the  sphincter  iridis  is  seen  at  the  anterior  part. 
The  lens  has  been  pushed  aside. 


FIG.  264. — SARCOMA  OF  CILIARY  BODY  INVADING  LENS,      x  60. 
After  Lawford,  R.  L.  O.  H.  Rep.,  xi.     Showing  invasion  of  the  posterior  part 
of  the  lens  by  a  melanotic  sarcoma  of  the  choroid  and  ciliary  body. 


THE    CILIARY    BODY  369 

The  prognosis  is  equally  unfavourable  for  each  group  of  cases. 
Seventeen  cases  treated  by  enucleation  were  followed  for  i  year  or 
more ;  local  recurrence  occurred  in  2,  i  of  which  died,  and  the  other 
was  described  as  a  myoma,  and  the  recurrence  took  place  after  5  years. 
Metastases  occurred  in  4  cases,  twice  in  the  liver,  once  in  the  stomach  or 
liver  and  in  the  skin,  once  apparently  in  the  other  eye,  ending  in  death 
at  the  end  of  a  year.  Eleven  were  healthy — 2  cases  after  i  year,  3 
after  i — 2  years,  3  after  2 — 3  years,  i  after  3^  years,  2  after  5  years 
(Groenouw). 

Sarcoma  of  the  ciliary  body  grows  almost  exactly  like  that  of  the 
choroid,  but  the  anatomical  relations  of  the  part  lead  to  slight 
differences.  It  usually  forms  a  rounded  projection  into  the  vitreous, 
the  thickness  of  which  is  rather  less  than  the  length.  It  does  not  so 
frequently  assume  the  mushroom  shape,  with  head,  neck,  and  base, 
which  is  so  characteristic  of  the  choroidal  growth,  and  this  is  partly 
due  to  the  splitting  up  of  Bruch's  membrane.  When  the  tumour 
starts  in  the  anterior  part  of  the  ciliary  body,  and  in  the  later  stages  of 
one  starting  farther  back,  it  invades  the  posterior  chamber,  pushing 
aside  the  lens  and  pushing  forward  the  iris.  The  iris  is  directly 
invaded  by  continuity,  and  may  become  embedded  in  the  growth 
(Fig.  263).  It  is  often  pushed  inwards,  so  that  the  growth  appears  in 
the  angle  of  the  anterior  chamber  and  gives  rise  to  irido-dialysis,  as 
already  mentioned.  It  may  then  progress  until  it  fills  the  anterior 
chamber. 

The  lens  is  at  first  merely  pushed  aside  or  distorted,  but  its  nutrition 
is  later  interfered  with,  so  that  it  becomes  opaque.  This  opacity  may 
assume  the  form  of  a  posterior  cortical  cataract  (Becker,  Salzmann).  The 
capsule,  like  all  hyaline  membranes,  offers  great  resistance  to  invasion, 
and  is  very  rarely  broken  through.  It  was  ruptured  in  Lange's  case 
("  myosarcoma  ").  Involvement  of  the  lens  in  the  growth  is  of  extreme 
rarity.  Such  an  event  has,  however,  been  recorded  by  Lawford  (Fig. 
264).  Small  islands  of  sarcoma-cells  lay  in  the  lens  substance 
between  the  lamellae  over  a  very  restricted  area.  They  appeared  to 
have  effected  an  entrance  a  little  distance  behind  the  equator,  i.e. 
where  the  capsule  is  naturally  much  thinner  and  less  resistant  than 
anterior  to  the  equator.  Continuity  between  the  islands  in  the  lens 
and  the  main  growth  in  the  ciliary  body  could  not  be  traced. 

In  many  cases  the  lens  is  merely  subluxated,  but  distortion  may  be 
extreme.  It  may  be  simply  flattened  or  more  or  less  deeply  excavated. 
In  Webster  and  Schwarzchild's  case  it  was  triangular  in  section. 

Detachment  of  the  retina  occurs  only  in  the  later  stages,  and  is 
naturally  posterior  to  the  growth.  It  was  absent  in  most  of  the  cases 
examined. 

Epibulbar  extension  takes  place  along  the  perforating  anterior 
ciliary  vessels,  especially  the  veins  (Fuchs),  and  is  of  frequent  and 
comparatively  early  occurrence.  There  is  usually  direct  continuity  of 
the  cells  along  the  perivascular  lymph-spaces,  but  the  most  exhaustive 
investigation  may  fail  to  trace  any  continuity  (Groenouw).  In  this 
case  the  cells  are  probably  carried  by  the  lymph-stream,  and  it  is 
interesting  in  this  connection  to  note  that  in  Groenouw's  case  the 

24 


THE    PATHOLOGY    OF   THE    EYE 


FIG.  265. — ANNULAR  SARCOMA  OF  CILIARY  BODY,      x  4. 

From  a  boy  &t.  14  (see  Text,  and  A.  f.  O.,  Iv,  2,  1903).     Note  the  infiltration 
of  the  iris  ;  also  the  intercalary  staphyloma. 


FIG.  266. — ANNULAR  SARCOMA  OF  THE  CILIARY  BODY,      x  65. 

From  the  same  specimen  as  Fig.  265.     The  ciliary  muscle  is  seen  to  the  right, 
the  cells  being  quite  different  from  those  of  the  growth. 


THE    CILIARY    BODY  371 

growth  was  an  alveolar  sarcoma,  /.  e.  probably  an  endothelioma.  In 
nearly  all  cases  with  epibulbar  extension  of  the  growth  there  is 
increased  intra-ocular  tension  (Fuchs).  It  is  not  always  easy  to  deter- 
mine whether  the  epibulbar  tumour  is  secondary  to  the  intra-bulbar 
one,  or  vice  versa.  This  is  shown,  for  example,  in  the  case  reported  by 
Verhoeff  and  Loring.  The  tension  of  the  eye  may  afford  valuable 
evidence  in  settling  this  point,  and  it  must  further  be  remembered  that 
intra-ocular  extension  of  extra-bulbar  growths  is  comparatively  rare,  and 
occurs  at  a  late  stage. 

The  minute  histology  of  sarcoma  of  the  ciliary  body — the  nature 
and   arrangement   of  the  cells,  pigmentation,    blood-vessels,   etc. — is 


FIG    267. — IRIS  FROM  CASE  OF  ANNULAR  SARCOMA  OF  CILIARY  BODY,      x  65. 

From  the  same  case  as  Figs.  265,  266.  The  iris  is  little  changed  in  form, 
but  it  is  densely  infiltrated  with  tumour  cells.  The  pupil  is  to  the  left.  Note  the 
very  wide  "  ertropion  of  uvea." 

identical  with  that  of  sarcoma  of  the  choroid,  and  will  be  fully  dis- 
cussed in  that  connection. 

Devereux  Marshall  has  described  a  rare  case  in  which  the  growth 
was  mainly  composed  of  a  large  cyst,  whilst  the  more  solid  part  also 
contained  numerous  cystic  spaces  of  variable  size.  It  was  a  mixed 
round-  and  spindle-celled  melanotic  sarcoma. 

It  is  extremely  rare  for  sarcoma  of  the  ciliary  body  to  be  multiple, 
but  a  case  of  two  small  spindle-celled  sarcomata  on  opposite  sides  of 
the  eye  has  been  recorded  by  Taylor. 

A  rare  form  of  sarcoma  of  the  ciliary  body  is  distinguished  by  its 
flatness  and  infiltrating  character,  so  that  it  extends  widely  with  little 
true  tumour  formation.  Owing  to  this  it  generally  invades  the  whole 


372 

circle  of  the  ciliary  body,  and  may  therefore  be  termed  a  ring  sarcoma 
(Ewetzky)  or  annular  sarcoma.  It  shows  the  same  features  as  the  rare 
flat  sarcoma  (Flachensarkom)  of  the  choroid  (q.v.). 

I  have  described  an  annular  sarcoma  of  the  ciliary  body  which  was 
found  in  the  eye  of  a  boy  aet.  14.  The  eye  had  been  injured  by  a  kick 
seven  years  previously,  and  was  removed  on  account  of  a  ciliary  staphy- 
loma.  The  ciliary  body  below  was  the  seat  of  a  leuco-sarcoma  (Fig.  265). 
Only  a  small  part  of  the  ciliary  muscle  was  intact ;  this  constituted  the 
posterior  part,  and  it  was  sharply  delimited  from  the  new  growth 
(Fig.  266).  Traces  of  the  ciliary  processes  were  seen  upon  the  surface, 
but  they  were  mostly  flattened  out,  the  growth  being  covered  by  the 
two  layers  of  retinal  epithelium,  which  were  little  altered.  The  growth 
was  a  typical  spindle-celled  sarcoma ;  the  individual  cells  were  of 
medium  length,  and  had  large  oval  nuclei.  There  was  no  difficulty  in 
distinguishing  them  from  the  neighbouring  unstriped  muscle-cells. 
The  growth  was  very  vascular.  There  were  a  few  small  patches  of 
dense  pigment,  mostly  near  the  surface.  These  had  every  appearance 
of  being  retinal  epithelium,  and  were  portions  of  the  superficial  pig- 
mented  epithelium  of  the  ciliary  processes  which  had  been  enclosed  in 
the  growth.  They  were  not  in  intimate  relation  with  the  blood-vessels  ; 
the  spindle-cells  and  the  intercellular  substance,  where  visible,  were 
quite  free  from  pigment. 

The  growth  was  of  the  infiltrating  type.  It  was  about  2  mm.  in 
thickness  at  the  thickest  part,  below.  It  had,  however,  infiltrated  the 
whole  ring  of  the  ciliary  body,  the  upper  part  being  entirely  replaced  by 
sarcoma  cells.  The  iris  stroma  was  similarly  replaced  below  and 
much  infiltrated  above  (Fig.  267).  The  cornea  and  sclera  at  the 
limbus  below  were  also  infiltrated,  the  cells  growing  along  the  planes  of 
these  tissues  in  their  inner  layers.  The  iris  above  consisted  of  a  small 
knob,  in  which  traces  of  the  sphincter  could  be  seen.  It  had  a  cap  of 
sarcoma  cells ;  peripherally  it  was  firmly  adherent  to  the  cornea,  was 
largely  replaced  by  sarcoma  cells,  and  had  a  dense  layer  of  retinal  pig- 
ment behind.  Below,  the  iris  was  free  for  2  mm. ;  it  was  thickened,  but 
retained  its  normal  shape.  The  stroma  was  entirely  replaced  by  new 
growth.  It  was  covered  behind  by  dense  retinal  pigment,  which 
extended  over  the  edge  and  along  the  anterior  surface  to  about  1  mm. 
from  the  attachment  to  the  cornea. 

The  staphyloma  consisted  of  a  very  thin  layer  of  fibrous  tissue,  the 
deeper  layers  of  which  contained  many  nuclei ;  it  was  apparently  free 
from  sarcoma  cells. 

Ewetzky's  case  8  was  a  typical  and,  up  to  that  time  (1898),  unique 
annular  sarcoma.  It  was  limited  to  the  iris  and  ciliary  body,  and 
extended  around  the  whole  circumference.  It  very  nearly  resembled 
the  case  described  above,  except  that  the  tumour  was  slightly  pig- 
rnented. 

Groenouw  recorded  in  detail  the  case  of  a  man,  aet.  28,  who  received 
a  blow  upon  the  left  eye  ;  three  weeks  later  a  swelling  was  noticed  at  the 
lower  edge  of  the  cornea,  and  six  weeks  after  this  there  was  a  smaller 
one  up  and  in.  After  enucleation  the  eye  was  found  to  be  enlarged  in 
all  dimensions ;  the  growth  infiltrated  the  ciliary  body  for  more  than 


THE    CILIARY    BODY  373 

half  the  circumference  at  the  lower  and  inner  part.  No  communication 
could  be  found  between  the  ciliary  and  the  epibulbar  growths.  The 
ciliary  growth  was  alveolar,  non-pigmented,  with  polygonal,  round,  and 
fusiform  cells,  showing  myxomatous  degeneration  in  parts.  In  places 
the  cells  were  epithelioid  in  type.  The  retina  was  in  situ,  covered 
internally  and  infiltrated  with  endothelial  cells.  The  disc  was 
cupped.  The  ciliary  growth  was  infiltrating,  distorting  the  parts  but 
little. 

Another  typical  ring  sarcoma  has  been  published,  viz.  that  by 
Kopetzky  von  Rechtperg ;  this  one  was  deeply  pigmented.  There  is 
every  reason  to  suppose  that  it  had  existed  for  at  least  twelve  years,  and 
slow  growth  is  indeed  apparently  characteristic  of  all  these  infiltrating 
sarcomata. 

Meyerhof  described  the  case  of  a  man,  set.  72  (case  iv),  with  an 
unpigmented  "  Flachensarkom  "  which,  starting  in  the  ciliary  body, 
spread  forwards  into  the  iris  and  backwards  into  the  choroid.  Two 
narrow  prolongations  passed  round  the  root  of  the  iris  for  several 
millimetres,  but  did  not  meet  upon  the  opposite  side.  Meyerhof  also 
recorded  another  incomplete  one  which  was  pigmented.  This  occurred 
in  a  woman  aet.  60.  It  invaded  both  choroid  and  iris,  and  there  was  a 
small  metastasis  in  the  pupillary  edge  of  the  iris.  The  base  of  the  iris 
and  angle  of  the  anterior  chamber  were  densely  infiltrated  almost  com- 
pletely round  the  eye,  forming  two  narrow  tongue- shaped  prolongations 
running  circumferentially  above  and  below  the  cornea.  Spindle-shaped 
cells  could  also  be  seen  in  the  area  between  these,  so  that  the  growth 
was  really  completely  annular.  Meyerhof  also  recorded  (case  vi) 
another  pigmented  complete  ring  sarcoma,  which  formed  a  circumscribed 
tumour  where  it  started  in  the  ciliary  body. 

There  are,  therefore,  now  six  cases  of  annular  sarcoma  of  the  ciliary 
body  on  record. 

Secondary  sarcoma  of  the  ciliary  body  is  invariably  by  continuity 
from  the  choroid  or  iris.  (See  also  "  Sarcoma  of  the  Choroid  "). 


*FucHS. — Das  Sarkom  des  Uvealtracttis,  Wien,  1882.  MULES. — T.  O.  S.,  viii, 
LAWFORD  AND  TREACHER  COLLINS. — R.  L.  O.  H.  Rep.,  xiii,  1890.  *GROENOUW. — A.  f.  O., 
xlvii,  2,  pp.  282  and  398,  1899.  *KERSCHBAUMER. — Das  Sarcom  des  Auges,  Wiesbaden, 
1900.  SALZMANN. — Wiener  klin.  Woch.,  1889.  LAWFORD. — R.  L.  O.  H.  Rep.,  xi,  p.  422, 
1887.  WEBSTER  AND  SCHWARZCHILD. — New  York  Med.  Jl.,  lix.  VERHOEFF  AND  LORING. — 
A.  of  O.,  xxxii,  1903.  DEVEREUX  MARSHALL.- — T.  O.  S.,  xv,  1895.  TAYLOR. — T.  O.  S., 
xii,  1892.  DERBY. — K.  M.  f.  A.,  xli,  Beilageheft,  1903.  *PARSONS. — A.  f.  O.,  Iv,  2,  1903. 

EWETZKY. A.     f.     O.,     xlv,     3,     1898.       KOPETZKY     V.     RECHTPERG. A.     f      O.,     Ill,     2,     IQOl. 

MEYERHOF. — K.  M.  f.  A.,  xxxix  and  xl,  1809.     *PARSONS. — A.  of  O.,  xxxiii,  1904. 


INDEX   OF    ILLUSTRATIONS 


(The  numbers  in  brackets  refer  to  the  figures  ;  the  others  to  the  pages.) 


Lids  (i)  (3)  (24)  (79),  2,  13,  55,  143 
Adenoma  : 

Meibomian  glands  (12)  (13),  26 

Moll's  glands  (14),  27 

Krause's  glands  (15),  28 
Cornu  cutaneum  (7),  17 
Cutaneous  horn  (7),  17 
Chalazion  (2),  10 
Ectropion  (3)  (24),  13,  55 
Elephantiasis  neuromatodes  (3     13 
Epithelioma  (9),  29 
Hair-follicles  in  myxcedema  (4),  14 
Henle's  glands  (i)  (17)  (33),  2,  33, 

69 

Krause's  glands  (i),  2 
Meibomian  glands  (i)  (3)  (8)  (24),  2, 

i>  20,  55 
Meibomian   glands    in   myxoedema 

(5).  U 

Moll's  glands  (i),  2 

Molluscum  contagiosum  (6),  15 

Myxoedema  (4)  (5),  14 

Neuro-fibromatosis  (3),  13 

(Edema  (3),  13 

Plexiform  neuroma  (3),  13 

Rodent  ulcer  (10)  (n),  23,  24 

Sarcoma  (8),  20 

Sulcus  subtarsalis  (i),  2 

Tarsal  cyst  (2),  10 

Waldeyer's  glands  (i),  2 

Zeiss's  glands  (i),  2 
Conjunctiva  (i)  (16)  (24),  2,  32,  55 

Bacteria  : 

Pneumococci  (18),  40 
Gonococci  (19),  42 
Koch-Weeks  bacilli  (20),  45 
Diplobacilli  (Morax-Axenfeld)  (21) 

(22),  47,  48  _ 
Diphtheria  bacilli  (23),  49 


Con  j  uncti  va — continued. 

"  Colloid  "  Degeneration  (53),  99 
Concretions  (51)  (52),  94,  95 
Conjunctivitis  : 

Diplobacillary  (24),  55 
Membranous  (25),  59 
Follicular  (36)  (37),  75 
Phlyctenular  (38),  76 
Nodular  (46),  85 
Cysts  (35)  (5 1)  (52)  (64)  (66),   71, 

94,  95>  127,  129 
Goblet-cells  (16)  (17)  (32)  (51)  (63) 

(64),  32,  33,  69,  94,  126,  127 
Henle's  glands  (i)  (17)  (33),  2,  33, 

69 

Herpes  iris  (25),  59 
Krause's  glands  (i),  2 
Lymphangioma  (16)  (63),  32,  126 
Ophthalmia  nodosa  (46),  85 
Pterygium  (54)  (204),  108,  306 
Spring  catarrh  (47)  (48)  (49)  (50), 

87,  88 

Sulcus,  subtarsalis  (i),  2 
Trachoma  (26)  (27)  (28)  (29)  (30) 

(30  (S*)  (33)  (3<)  (35).  60,  63, 

64,  65,  67,  68,  69,  70,  71 
Tubercle  (39)  (40)  (41)  (42)  (43)  (44) 

(45),  79,  80,  81,  82,  83 
Tumours  : 
Angioma  : 

Cavernous  (61)  (62),  124 

Lymphangioma  (16)  (63),    32, 

126 

Dermoid  (71)  (72)  (73),  133,  134 
Dermo-lipoma  (74),  136 
Epithelial  plaques  (67)  (68)  (69) 

(70),  130,  131,  132 
Epithelioma  (77)  (78)   (79)  (80) 

(82),  142,  143,  144,  145 


376 


INDEX   OF    ILLUSTRATIONS 


Conjunctiva— continued. 
Tu  mou  rs — continued. 
Fibroma  (59),  122 
Fibro-myxoma  (60),  123 
Granuloma  (43)  (44)  (45 )  (56)  v57) 

(58),   82,   83.    120,    121 

Ntevus  (52)  (64)  (65)  (66),   95, 

I2'/,    128,    129 

Osteoma  (75),  137 
Papilloma  (55)  (81),  118,  144 
Sarcoma  (76),  138 
Waldeyer's  glands  (i),  2 
Cornea : 

Abrasion  (99)  (100),  166,  167 
Anterior  staphyloma  (ioi)(io2)(io5) 
(106)  (107)   (163),    1 68,    169, 
171,  172,  240 
Arcus  senilis  (160),  230 
Atrophy,  Peripheral  (170),  248 
Blood-staining    (171)    (172)    (173) 

(i74),  249,  250,  251,  252 
Bowman's  membrane  : 
Fibrillation  of  (134),  207 
Infiltration  (131)  (152),  205,  226 

on  ulcer  (130),  204 
Rupture  (85)  (91)  (96)  (99)  (100), 

154,  160,  164,  166,  167 
Wrinkling  (118)  (175),  182,  254 
Bullous  keratitis  (116),  178 
Calcification  (148)  (164),  221,  242 
Cystoid  cicatrix  (90),  159 
Cysts  (175)  (176)  (177),  254,  255 
Descemet's  membrane  : 

"  Early  perforation  "  (140),  212 
Fibrillation  of  (140),  212 
Rupture  (85)  (89)  (91)  (96)  (105) 
(108),  154,  158,  1 60,  164,  171, 

173 

Wrinkling  (117),  181 
Epithelium : 

Atrophy  (109)  (124)  (125)  (126) 

(153)  (154)  (155)  (156)  (158), 

J75.  J95>  J96>  i9'7»  226,  227 

Desiccation  (158),  227 

Desquamation  (114)  (115)  (128) 
(129)  (130)  (137)  (144)  (145) 
(146X148)  (159),  177,  203,  204, 

209,   2l8,  219,   221,   227 

Horny  (102)  (106),  169,  171 
Infiltration  (16)  (33)  (36)  (38)  (50) 
(81)    (125)    (126)    (129)    (151) 
(iS7),  32,  69,  75,  76,  88,  144, 
196,  197,  204,  224,  227 


Cornea — continued. 

CEdema(88)(95)(io9)(iio)(iii) 
(112)  (113)  (116)  (125)' (126) 
(127X163),  158,  163,  175,  177, 
178,  196,  197,  203,  240 

Epithelium,  Cocain  on  (127)  (12.3) 
(129),  203,  204 

Filamentary  keratitis  (119)  (120), 
183,  184 

Hyaline  degeneration  (108)  (161) 
(x6*)(x6j)(x66),  173,238,239, 
240,  244 

Hyphsema  (137)  (207),  209,  308 

Hypopyon  (132)  (137)  (140)  (141) 
(M5)  (J93)  (206)  (207),  205, 
209,  212,  215,  218,  293,  308 

Infiltration  (121)  (122)  (123)  (124) 
(130)  (131)  (132)  (133)  (134) 
(135)  (136)  (137)  (138)  (139) 
(140)  (141)  (142)  (143)  (144) 
(145)  (146)  (147)  (149)  (150) 
(151)  (159)  (160)  (161)  (162) 
(163)  (164)  (166)  (171)  (172) 
(173X174)  (207),  187,  188,192, 
195,  204,  205,  206,  207,  208, 

209,  2IO,     211,     212,     215,     2l6, 

217,  2l8,     219,     22O,     223,     224, 

227,  230,     238,     239,     240,     242, 

244,  249,    250,    251,   252,   308 

Infiltration,  Peripheral  annular  (143) 

(145)  (146),  217,  218,  219 
Infiltration,     Peripheral     superficial 

(144),  218 

Inflammatory  spindles  (122),  188 
Keratectasia  (108)  (162),  173,  239 
Keratitis  (121)  (122),  187,  188 
Interstitial  (123)  (194)  (195),  192, 

296,  298 

Mycotic  (141)  (142),  215,  216 
Primary  (152),  226 
Phlyctenular  (cf.  115),  177 
"  Keratitis  punctata"  (191),  290 
Leucoma    (134)    (135).  (J48),    207, 

221 

Leucoma  adhaerens  (104),  170 

Mycelium  of  Aspergillus  (142),  216 

Nebula  (100),  167 

(Edema  (83)  (86)  (88)  (95)  (109) 
(no)  (in)  (112)  (113)  (117) 
(125)  (126)  (127)  (133)  (166) 
(169),  152,  157,  158,  163,  175, 
177,  181,  196,  197,  203,  206, 
244,  246 


INDEX   OF    ILLUSTRATIONS 


377 


Cornea — continued. 
Opacity  : 

Band-shaped   (161)    (165)   (166), 

238,  243,  244 

Nodular  (167)  (168)  (169),  246 
Pannus    degenerativus   (124)    (125) 
(126)  (201),  195,  196,  197,  303 
Pigmentation  (171)  (172)  (173)  (174) 

(202),  249,  250,  251,  252,  305 
Pseudo-cornea  (94)  (103),  163,  169 
"Ring  Abscess"  (143)  (145)  (146), 

217,  218,  219 

Sclerosis,  Peripheral  (170),  248 
Striate  opacity  (117),  181 
Tumours  : 

Endothelioma  (180)   (181),    261, 

262 

"Horn "(178),  256 
Sarcoma  (179)  (180)  (181),   260, 

261,  262 
Ulcer  (130)  (131)  (132)  (133)  (136) 

(*37)  (i38)  (X39)  (140)  (141) 
(142)  (143)  (145)  (146)  (147) 
(148)  (149)  (150)  (151),  204, 

205,  2O6,  2O8,  209,  2IO,  211, 
212,  215,  2l6,  217,  2l8,  219, 
220,  221,  223,  224 

Ulcer,  Marginal  (147),  220 
Atheromatous  (148),  221 
Mooren's  (149)  (150)  (151),  223, 

224 

Wounds  (83)  (84)  (85)  (86)  (87)  (88) 
(89) (90) (91) (92) (93) (94)  (95) 
(96)  (97)  (98)  (138)  (143)  (145) 
(146),  152,  153,  154,  157,  158, 
159,  160,  161,  162,  163,  164, 
165,  210,  217,  218,  219 
Sclerotic : 

Scleritis,  Annular  (182)  (183),  274, 

275 
Iris: 

Atrophy  (89)  (90)  (191)  (197)  (198) 

(203)  (204)  (205)  (210)  (211). 

158,   159,   290,  301,   305,   306, 

310 

Bombe  (87)  (187),  157,  288 
Cysts  (212)  (213)  (214)  (216)  (217) 

(218)  (219)  (220)  (221)  (222) 

(223)5  3I3.  3U,  3J5>  3l6>  3i9, 
320 

"  Ectropion  of  uveal  pigment  "  (89) 
(196)  (256)  (267),  158,  300, 
352?  37i 


I  ris — con  tin  ued. 

Endothelium  on  iris  (199),  302 
Epithelium  on  (97)  (98)  (215)  (220), 

164,  165,  314,  316 
Fibrous  tissue  on  iris  (191)  (208), 

290,  309 

Horse's  (226),  323 
Hyaline  membrane  on  iris  (89)  (97) 

(200),  158,  164,  302 
Iritis : 

Acute  (138)  (186)  (193),  210,287, 

293 
Chronic  (191)  (208)  (209),  290, 

3°9 

Nodular  (192),  292 
Plastic  (186),  287 
Purulent  (193)  (206)  (207),  293, 

308 

Tubercular  (194)  (195),  296,  298 
New  vessel  on  iris  (198),  301 
Occlusio  pupillae  (187)  (189),    288, 

289 
Prolapse  (86)  (89)  (90),    157,   158, 

159 
Pupillary    membrane    (192)   (201), 

292,  303 

Retraction  (117),  181 
Seclusio  pupillae  (188),  289 
Synechia  : 

Anterior  (85)  (88)  (91)  (97)  (104) 
(136)  (i37)  (200)  (201)  (220), 
154,  158,  160,  164,  170,  208, 
209,  302,  303,  316 
Peripheral  anterior  (89)  (90)  (92) 
(94)  (163)  (182)  (187)  (188) 
(189)  (195)  (199)  (203)  (204) 
(205),  158,  159,  161,  163,  240, 
274,  288,  289,  298,  302,  305, 
306 
Posterior  (94)  (137)  (188)  (189) 

(190),  163,  209,  289,  290 
Total  Posterior  (190),  290 
Ring  (94)  (188),  163,  289 
Tumours  : 

Naevus,    Melanoma    (224)   (225) 

(227)  (228),  323,  324 
Myoma  (?)  (229),  327 
Sarcoma  (230)  (262)  (263)  (265) 

(267),  328,  366,  368,  370,  371 
Glioma  (232)  (233),  331,  332 
Angle  of  Anterior  Chamber : 
Cholesterin  in  (208),  309 
Foetal  (185),  284 


373 


INDEX    OF    ILLUSTRATIONS 


Angle  of  Anterior  Chamber — cont. 
Hyphaema  (137)  (207),  209,  308 
Hypopyon  (132)  (137)  (140)  (141) 
(J45)   (l93)   (2°6)   (207),    205, 

209,    212,    215,    2l8,   293,   308 

Normal  (184)  (202),  283,  305 
Occluded,  see  Synechia,  Peripheral 

anterior 
Pigment  in  (209)  (210)  (211),  309, 

310 
Tumours  : 

Endothelioma  (231),  331 
Glioma  (232),  331 

Ciliary  Region,  Normal  (184),  283 
Staphyloma,  Intercalary  (265),  370 
Ciliary  Body  : 

Atrophy  (182)  (255)  (258),  274,  351, 

359 
Bone  in  cyclitic  deposits  (248)  (249) 

(250)  (251)  (252)    (253),    345, 

347.  348 

Cyclitis  (237—256),  338—352 

Acute   (237)    (239)    (240)    (241) 
(242)    (243)    (254),    338,    339, 

34°,  34i,  35° 

Chronic  (117)  (238)  (243)   (245) 
(246)  (247)   (248)  (249)    (250) 

(251)  (252)    (253)   (256),    181, 
338,  34i,  343,  341,  345>  347, 

348,  352 

Purulent  (193)  (206)  (207),   293, 

308 

Syphilitic  (257),  355 
Glands  (234)  (235),  325 

Proliferation  of  (245)  (246)  (247), 

343,  344 
Tumours    of    (259)    (260),     361, 

362 

Gumma  (257),  355 
Prolapsed  (93),  162 
Tumours  : 

Epithelial  hyperplasia  (258),  359 
Carcinoma  (?)(259)(26o),  361,  362 
Sarcoma  (261)  (262)  (263)  (264) 
(265)  (266),  365,  366,  368.  370 
Wound  (236),  337 
Lens  : 
Adhesion  to  cornea  (94)  (136),  163, 

208 

Anterior  capsular  cataract  (i  02)  ( 1 04) 
(187)  (190)  (223),  169,  170,  288, 
290,  320 
Calcification  (87),  157 


Lens — continued. 

Cataract  (87)  (102)  (104)  (136)  (137) 
(139)  (182)  (190)  (192)  (206) 
(207)  (220)  (223),  157,  169,  170, 

2O8,     209,     211,     274,     290,     292, 
308,   316,   320 

Prolapsed    capsule    (86)    (91)    (92) 

(103),  157,  160,  161,  169 
—  fibres  (92),  161 
Sarcoma  (264),  368 
Subluxation  (262),  366 
Vitreous : 

Anterior    synechia    (87)    (88),    157, 

158 
Bone  in  (249)  (250)  (25 1)  (252X253), 

345,  347,  348 

Exudate  (193)  (206)  (2:57)  (239X240) 
(241)  (242)  (243)  (244)  (248), 
293,  308,  338,  339,  340,  341, 

345 
Retina : 

Acute  retinitis  (239X240)  (241X242) 

(243),  339,  340,  34i 
Detached    (92)    (190)    (223)    (238) 
(256)  (261),  161,  290,  320,338, 

352,  365 
Foetal  (185),  284 
Glioma  (232)  (233),  331,  332 
General : 

Arterio-sclerosis  (5),  14 
Epithelial  downgrowth  : 

between    corneal   lamellae    (131), 

205 

Epithelioma  (9),  21 
into   anterior  chamber  (86)   (95) 

(96)  (97)  (98)  (175)  (176)  (i77), 

157,  163,  164,  165,  254,  255 
Spring  catarrh  (48)  (49)  (50),  87, 

88 
Trachoma  (31)  (33)  (34)  (35),  68, 

69,  70,  71 

Epithelioid  cells  (57),  120 
Epithelium,  Horny  (68)  (69)  (102) 

(106),  131,  169,  171 
Epithelium,    Levelling   tendency  of 

(87)  (99)  (i°°)  (i34),  157,  166, 

167,  207 
Epithelium    on    ulcer    (132)    (139), 

205,  211 
Follicles   (26)  (30)  (36)    (37)   (45), 

60,  67,  75,  83 
Giant-cells  (2)  (43)  (45)  (46),  10,  82, 

83,85 


INDEX    OF    ILLUSTRATIONS 


379 


General — continued. 

Goblet-cells  (16)  (17)  (32)  (51)  (63) 
(64),  32,  33,  69,  94,  126,  127 

Hyaline  degeneration  (10)  (53)  (54) 
(72)    (108)    (,6i)    (162)    (16)3 
(166),    23,   99,    108,    134,    173, 
238,  239,  240,  244 
of  vessels  (205),  306 

Hyaline  membrane  : 

on  iris  (89)  (97)  (200),   158,  164, 
302 


General — continued. 

H  yaline  membrane — continued. 

on  organised  vitreous  (87),  157 
Kerato-hyalin  (68)  (69)  (106),  131, 

171 

Microphthalmia  (185).  284 
Papillae : 

Anterior  staphyloma  (106),  171 

Fibroma  (59);  122 

Spring  catarrh  (47)  (48),  87 

Trachoma  (31),  68 


INDEX 


(Where  there  are  several  references  the  most  important  is  printed  in  italics.} 


Abrasions  of  cornea,  166 
Adenoid  tissue  of  conjunctiva,  34 
Adenoma  of  caruncle,  147 

—  of  ciliary  body,  360 

—  of  conjunctiva,  138 

—  of  glands  of  lids,  26 
Amyloid  degeneration,  96 

—  in  anterior  staphyloma,  172 

—  in  conjunctiva,  96 

—  in  conjunctivitis  petrificans,  92 

—  in  cornea,  237 

—  in  trachoma,  71 

—  tests  for,  101 

Angioma :  see  Hsemangioma,  Lymphangioma. 
Angle  of  anterior  chamber,  304 

—  coagula  in,  307 

—  leucocytes  in,  311 

—  obliteration  of,  304 

—  pigment  in,  311 

—  tumours  of,  331 
Annular  infiltration, 

—  sarcoma,  372 

—  scleritis,  273 

—  synechia,  289 

Anterior  chamber,  normal,  282 

—  staphyloma,  168 

—  synechia,  156 
Arcus  senilis,  230 
Argyrosis,  no,  253 
Aspergillus  fumigatus,  215 
Atrophy  of  ciliary  body,  357 

—  of  iris,  300 

—  of  lids,  14 

—  of  tarsus,  15 
Atropin  irritation,  75 
Attenuated  tubercle  of  iris,  295 


Aqueous  in  hypopyon  ulcer,  206 

—  in  irido-cyclitis,  307 

—  normal,  206 

Bacillus  coli  communis,  43,  5J 

—  diphtheria,  39,  49,  52,  58,  213 

—  influenza,  54 

-  Koch-Weeks,  42,  44,  49,  54,  73 

—  leprce,  7 

—  Morax-Axenfeld,  12,  47 

—  mucosus  ozantz,  10,  54 

—  of  marginal  ulcer  (zur  Nedden),  48,  221 

—  of  Mooren's  ulcer  (Andrade),  225 

—  of  Miiller,  46 

—  of       peripheral       annular       infiltration 

(Hanke),  220 

-  of  Petit,  48 

—  of    superficial   punctate   keratitis    (Her- 

bert), 202 

—  pneumonia  (Friedlander),  12,  48,  54 

—  pyocyaneus,  54 

—  septatus  (Gelpke),  52 

—  xerosis,  12,  35,  50,  57,  91,  103,  213 
Bacteriology  of  chalazion,  1 1 

—  of  conjunctiva,  35 

—  of  conjunctivitis,  37 

—  of  hypopyon  ulcer,  213 

—  of  marginal  ulcer,  221 

—  of  Mooren's  ulcer,  225 

—  of  pemphigus,  91 

—  of  peripheral  annular  infiltration,  220 

—  of  phlyctenular  conjunctivitis,  77 

—  of  superficial  punctate  keratitis,  202 

—  of  trachoma,  73 
Band-shaped  opacity,  243 
"  Bitot's  spots,"  102 


INDEX 


Blastomycetes,  257 
Blepharitis  acarica,  5 

—  squamosa,  4 

—  ulcerosa,  4 
Blepharochalasis,  15 
Blepharo-conjunctivitis,  47 
Blood-staining  of  cornea,  249 
Bombe  iris,  289 
Bowman's  corneal  tubes,  149 

—  membrane,  150 

—  calcareous  deposits  in,  242 

—  hyaline  deposits  on,  228 

—  wrinkling  of,  182,  247 

—  wounds  of,  151,  1 66 
Bruch's  membrane,  284 
Briicke's  muscle,  334 

Calcification,  14,  92,  221,  241 

—  in  ciliary  body,  357 

—  in  cyclitis,  346 
-  in  iris,  303,  304 

—  of  conjunctiva,  92 

—  of  cornea,  221,  241,  243 

—  of  sclerotic,  279 

—  of  tarsus,  14 

—  tests  for,  242 
Calculi  in  angiomata,  125 
Canities,  5 

Carcinoma  of  caruncle,  147 

—  of  ciliary  body,  361 

—  of  iris,  329 

—  of  glands  of  lids,  28 

—  of  sclerotic,  281 
Caruncle,  35 

—  supernumerary,  29 

—  tumours  of,  146 
Caterpillar  hairs,  84 
Chalazion,  10 
Cholesteatoma,  312 
Cholesterin,  173,  236 
Chromatophores  :  see  Pigment  cells. 
Cicatrisation  in  trachoma,  70 

—  of  cornea,  154 

Cilia  in  anterior  chamber,  312,  315 

—  in  corneal  wounds,  162 

—  diseases  of,  4,  5,  8,  10,  14 
Ciliary  body,  atrophy  of,  173 

—  cysts  of,  358 

—  degeneration  of,  357 

—  inflammation  of,  336 

—  normal,  334 

—  prolapse  of,  161 


Ciliary  body,  tumours  of,  359 

—  wounds  of,  336 

Cocain,  effect  on  epithelium  of  cornea,  203 

—  —  on  wounds  of  cornea,  155 
"  Cock's  comb  "  excrescences,  80 
Collagen,  98 

Collastin,  100 

Colloid  degeneration,  96,  237 

—  in  pinguecula,  105 

-  in  pterygium,  108 

—  see  also  Hyaline  degeneration. 
Concretions  in  conjunctiva,  93 
Condyloma  :  see  Syphilis. 
Confluent  tubercle  of  iris,  297 
Conglomerate  tubercle  of  iris,  297 
Congenital  cysts  of  conjunctiva,  1 17 

—  tumours  of  conjunctiva,  127 

—  —  of  cornea,  258 

-  of  lids,  28 

-  —  see  also  Naevus,  dermoid,  etc. 
Conical  cornea,  174 
Conjunctiva,  concretions  in,  93 

—  cysts  of,  Hi 

—  degeneration  of,  93 

—  inflammation  of,  37 

—  normal,  30 

—  oedema  of,  58 

—  pigmentation  of,  no 

—  sterilisation  of,  36 

—  tumours  of,  1 17 
Conjunctivitis,  angular,  47 

—  bacteriology  of,  37 

—  catarrhal,  44,  47 

—  chronic  membranous,  50 

-  congenital,  39,  40,  42,  53 

—  endogenous,  39,  41 

—  follicular,  74 

—  histology  of,  54 

—  lymphatica,  86 

—  membranous,  39,  49,  54,  58 

—  muco-purulent,  44 

—  Parinaud's  lacrymal,  38 

—  petrificans,  92 

—  phlyctenular,  76 

—  pseudo-tubercular,  84 

—  purulent,  42 

—  verrucosa,  86 
Cornea,  abrasions  of,  166 

—  cysts  of,  253 

—  degenerations  of,  225 

—  ectasia  of,  173 

—  filaments  on,  183 


382 


INDEX 


Cornea,  inflammation  of,  185 

—  normal,  148 

—  oedema  of,  152,  175,  246 

-  pigmentation  of,  249 

—  striate  opacity  of,  179 

—  tumours  of,  256 

—  wounds  of,  151 

Corneous  epithelium,  103,  130,  170,  228,  240 

-  in  anterior  staphyloma,  170 

—  in  trachoma,  68 
Cornu  cutaneum,  16 
"  Coryna  "  bacilli,  53 
Crampton's  muscle,  335 
Cyclitis,  acute,  336 

—  chronic,  349 

-  plastic,  353 

—  nodular,  353 

—  serous,  349 

—  suppurative,  336 

—  sympathetic,  353 
Cysticercus,  112,  116,  280,  321 
Cystoid  cicatrix,  159 

Cysts,  bacterial,  115 

—  complex,  321 

—  congenital,  117,  280,  318 

-  "false,"  115,  255 

—  in  conjunctivitis,  57 

—  in  naevi,  129 

-  in  trachoma,  69 

-  lymphatic,  114,  7/5,  254 

—  of  caruncle,  147 

—  of  ciliary  body,  358 

—  of  conjunctiva,  1 1 1 

—  of  cornea,  253 

—  of  corneal  epithelium,  176,  254 

—  of  iris,  160,  254,  311 

—  of  Krause's  glands,  113 

—  of  lids,  25 

—  of  Meibomian  glands,  25,  72 

—  of  Moll's  glands,  25,  73 

-  of  new-formed  glands,  57,  69 

-  of  retinal  epithelium,  318 

—  of  sclerotic,  279 

—  parasitic,  116,  280,  321 

-  pseudo-,  1 1 6,  255 

—  sebaceous,  25 

—  serous,  114,  254 

Degeneration,  fatty,  230,  237,  279 

—  of  ciliary  body,  357 

—  of  conjunctiva,  93 

—  of  cornea,  225 


Degeneration  of  epithelium,    176,    196,    203, 
225 

—  of  iris,  300 

—  of  sclerotic,  279 
Dermoid  cyst  of  iris,  318 

—  of  caruncle,  147 

—  of  conjunctiva,  132 

—  of  cornea,  258 

—  of  lids,  29 
Dermo-lipoma,  135 
"  Descemetitis,"  349 

Descemet's  membrane,   "  early  perforation  " 

of,  211 
—  folding  of,  180 

—  hyaline  deposits  on,  229 
-  normal,  150 

—  prolapse  of,  170,  174 

—  rupture  of,  174 

—  wounds  of,  154 
Desiccation  of  epithelium,  228 
Desquamation  of  epithelium,    176,  203,  225, 

342 
Diabetes,  iris  in,  320 

—  striate  opacity  in,  180 
Dilatator  iridis,  284 

Diphtheria  bacillus,  39,  49,  52,  58,  213 
Diphtheria    of    conjunctiva,    49.       See    also 

Conjunctivitis,  membranous 
Diplobacillus  liquefaciens  (Petit),  48 

—  of  Morax-Axenfeld,  47 
Diplococci  in  trachoma,  73 
Diplococcus  gonorrhcese  :  see  Gonococcus 

—  lanceolatus  :  see  Pneumococcus 
Distichiasis,  4 

Drying  of  epithelium,  228 

"  Drusen,"  228,  229 

"  Dystrophie  marginale,"  248 

"  Early    perforation  "  of    Descemet's    mem- 
brane, 21  I 

Ectasia  of  cornea,  173 
Ectropion,  4 

"  Ectropion  of  uveal  pigment,"  300 
Eczematous  conjunctivitis,  76 
Elacin,  100 
Elastic  tissue  in  anterior  staphyloma,  172 

—  in  pinguecula,  104 
-    in  pterygium,  no 

—  of  conjunctiva,  in 

—  of  cornea,  150 

—  of  sclerotic,  266 
Elephantiasis  Arabum,  12 


INDEX 


383 


Elephantiasis  lymphangioides,  12 

—  neuromatodes,  12 

Endothelioma  of  angle  of  anterior  chamber, 

33* 

—  of  ciliary  body,  363 

—  of  conjunctiva,  129,  140 

—  of  cornea,  259 

—  of  lids,  20 

Endothelium  in  interstitial  keratitis,  193 

—  in  oedema  of  cornea,  179 

—  of  cornea,  149 
Eosinophiles  in  spring  catarrh,  89 

—  in  trachoma,  66 
!>pidermidoma,  312 
Episcleritis,  270 

—  periodica  fugax,  271 

Epithelial  hyperplasia  of  ciliary  body,  359 

—  plaques,  130 
Epithelioma  of  caruncle,  147 

—  of  ciliary  body,  359 

—  of  conjunctiva,  141 

—  of  cornea,  262 

—  of  lids,  21 

-  of  sclerotic,  281 
peribulbar,  142,  146 

Epithelium,  desiccation  of,  228 

—  desquamation  of,  176,  203,  225 

—  hyaline  deposits  in,  240 

-  in    anterior    chamber,     163,     165,    253, 

312 

—  in  anterior  staphyloma,  170 

—  in  pannus,  196 

—  in  spring  catarrh,  87 

—  in  trachoma,  68 

—  retinal,  of  iris,  285 

—  vacuolation  of,  176 
Eserin  irritation,  75 

Essential  shrinking  of  conjunctiva,  89 
Experimental  tubercle  of  iris,  298 
Eyelashes,  diseases  of,  4,  5,  8,  10,  14 

—  in  anterior  chamber,  312,  315 

—  in  corneal  wounds,  162 

"  Fadchenkeratitis,"  183 

"  Faltentriibung,"  179 

Fatty  degeneration  in  cyclitis,  346 

-  —  of  cornea,  230,  237 
Favus  of  lids,  8 

Fibro-chondroma  of  sclerotic,  280 
Fibro-fatty  tumour  of  conjunctiva,  135 
Fibroma  of  conjunctiva,  122 

—  of  cornea,  257 


Fibroma  of  lids,  17 

—  of  sclerotic,  280 
Filamentary  keratitis,  183 
Filaria  in  anterior  chamber,  321 

—  in  conjunctiva,  117 
Fistula,  corneal,  162 

"  Flachensarcom,"  372 
Fluorescein,  179,  194 
Follicles,  34,  60,  74 
Follicular  conjunctivitis,  74 
"  Friihperforation,"  211 
Fuchsinophile  bodies,  257 
"  Furchenkeratitis,"  249 
"  Furrow  keratitis,"  248 

Gehrke  and  Kain's  coccus,  58 
Gerontoxon,  230 
Giant  cells,  78 
in  cornea,  162 

—  —  in  ophthalmia  nodosa,  85 

—  in  sarcoma,  140 

—  in  trachoma,  66.     See  also  Tubercle 
"  Gitterige  keratitis,"  247 

Glands,  accessory  lacrymal,  34 

—  Baumgarten's,  34 

—  Ciaccio's,  3 

—  Harderian,  34 

—  Henle's,  33 

-  Krause's,  3,  34,  73 

-  Meibomian,  2,  72 

-  Moll's,  i,  73 

—  new-formed  conjunctiva!,  57,  93,  114 

—  of  ciliary  body,  335 

-  cysts  of,  358 

—  proliferation  of,  343 

—  tumours  of,  360 

—  posterior  tarsal,  3 

—  "  trachoma,"  60,  69 

—  tumours  of  palpebral,  24 

-  Waldeyer's,  3 

—  Zeiss's,  i 

Glioma  of  angle  of  anterior  chamber,  332 

—  —  of  ciliary  body,  363 

—  —  of  sclerotic,  281 

-  on  iris,  333 
Glycogen,  89,  173,  241 

—  in  anterior  staphyloma,  173 

—  in  iritis,  288 

—  in  spring  catarrh,  89 
Goblet  cells,  31,  56 

—  in  trachoma,  68 
Gonococcus,  41,  50,  58,  213 


384 


INDEX 


Granular  lids  :  see  Trachoma 
Granuloma,  simple,  119 
Gumma  :  sen  Syphilis 

Haemangioma  of  conjunctiva,  123 

-  of  iris,  325 

-  of  lids,  18 
Hajmatoidin,  250 
Hsemosiderin,  250 

"  Half-moon  "  cells,  70 
Herpes  cornese,  178 

-  iris,  58 
Hordeolum,  10 
Horn,  corneal,  256 

—  cutaneous,  16 

Horny  epithelium,  103,  130,  170,  228,  240 

—  —  in  anterior  staphyloma,  170 

—  —  in  .trachoma,  68 
"  Hyalin,"  97,  105,  238 
Hyaline  degeneration,  93,  g6 

—  in  anterior  staphyloma,  172 

—  in  ciliary  body,  357 

—  in  conjunctivitis  petrificans,  92 

-  in  cornea,  228,  229,  237,  243,  246,  247 

—  —  in  epithelium,  240 
—  in  keratectasia,  174 

—  in  pinguecula,  104 

—  in  pterygium,  109 

—  in  sclerotic,  279 

— •  in  trachoma,  65,  71 

—  of  scar  tissue,  172,  174,  241 
Hyaline  deposits  in  iris,  303 

—  —  on  Bowman's  membrane,  228 

—  —  on  Descemet's  membrane,  229 
on  iris,  291 

Hyaline  membrane  on  iris,  156,  304 

—  on  organised  vitreous,  159 
Hyperplasia  of  sclerotic,  280 
Hypertrophy  of  lids,  12 
Hyphsema,  31 1 

Hypopyon,  206,  212,  337 

—  ulcer,  206,  208,  215 

Implantation  cysts  of  conjunctiva,  112 

—  of  cornea,  253 

—  of  iris,  312 

Infiltration,  peripheral  annular,  217 

—  posterior,  2IO 
Infiltration  ring,  Leber's,  186 
Inflammation  of  ciliary  body,  336 

—  of  conjunctiva,  54 

—  of  cornea,  185 


Inflammation  of  glands  of  lids,  10 

—  of  iris,  286 

—  of  lids,  4 

—  of  sclerotic,  270 
Inflammatory  spindles,  188 
Interstitial  keratitis,  igi,  200,  201 
Iris,  bombe,  289 

—  cysts  of,  311 

—  degeneration  of,  300 

—  inflammation  of,  286 

—  normal,  282 

•-   prolapse  of,  156,  159,  168 

—  tumours  of,  322 

—  wounds  of,  286 
Iritis,  acute,  286 

—  chronic,  291 

—  endogenous,  41 

—  nodular,  292 

—  pseudo-tubercular,  292 

—  purulent,  293 

—  syphilitic,  294 

—  tubercular,  295 

Keratectasia,  173 
"  KeYatite  goutteuse,"  246 
Keratitis,  annular,  191 
—  band, 243 

—  bullous,  175,  776 

—  disciform,  191 

—  filamentary,  183 
-  "  Gitterige,''  247 

-  hypopyon,  206,  208,  215 

—  induced,  186 

—  in  general,  185 

—  interstitial,  igi,  200,  201 

—  maculosa,  202 

—  mycotic,  215 

—  neuro-paralytic,  228 

—  nodular,  245 

—  parenchymatous,  igi,  200,  201 

-  phlyctenular,  190 
"  punctata,"  349 

—  purulent,  203 

—  reticular,  247 

—  sclerosing,  202 

—  sequestrating  scar,  221 

—  subepithelialis,  202 

—  superficial,  54 

—  punctate,  201,  202 

—  trophic,  243 

—  tubercular,  199 

—  vesicular,  175,  176 


INDEX 


385 


Keratocele,  174 

Keratoconus,  174 

Keratohyalin,  103,  170 

Keratomycosis,  215 

"  Knotchenformige  Hornhauttriibung,"  245 

"  Korperchenzellen,"  64 

Lamina  fusca,  267 

"  Late  infection,"  222 

Lens,  adhesion  to  cornea,  156,  162 

—  capsule  in  wound,  161 

—  in  cyclitis,  343 
Leproma  :  see  Leprosy 
Leprosy  of  ciliary  body,  356 

—  of  conjunctiva,  84 

—  of  cornea,  201 
—  of  iris,  299 

-  of  lids,  7 

—  of  sclerotic,  279 
Leucoma,  167 

Leukaemic  tumours  of  lids,  19 

"  Levelling  tendency"  of  epithelium,  105 

Lids,  atrophy  of,  14 

—  cysts  of,  25 

—  hypertrophy  of,  12 

—  inflammation  of,  4 

—  inflammation  of  glands  of,  10 

—  normal,  i 

—  redema  of,  12 

—  tumours  of,  15 

—  tumours  of  glands  of,  24 
Ligamentum  pectinatum  iridis,  282 
Lipoma  of  caruncle,  147 

—  of  conjunctiva,  136 

-  of  lids,  1 8 

Lupus  of  conjunctiva,  80 

—  of  lids,  6 
Lymphadenoma,  18 
Lymphangiectasis,  125 
Lymphangioma  of  caruncle,  147 

—  of  conjunctiva,  125 

-  of  lids,  18 

Lymphectaria  haemorrhagica,  126 
Lymphocytes,  50 

—  in  trachoma,  63 
Lymphoma  of  conjunctiva,  121 

—  of  lids,  19 

Lymphosarcoma  of  conjunctiva,  122,  141 

-  of  lids,  1 8 

Madarosis,  4 

Margo  intermarginalis,  2,  30 


Mast  cells,  56 

—  —  in  cyclitis,  337 
in  fibroma,  17 

—  in  iritis,  287 

—  • — -in  trachoma,  66,  70 
Melanoma,  129,  322 
Meningococcus,  44 

Metallic  deposits  in  cornea,  253 

Micrococcus  flavus  desidens,  77 

Microsporon  in  trachoma,  74 

Miliary  tubercle  of  iris,  296 

Milium,  24 

Miosis,  285 

Molluscum  contagiosum,  15 

—  fibrosum,  17 
Monilethrix,  5 
Mucin,  31,  247 
Miiller's  muscle,  334 

"  Mutton-fat  "  k.p.,  349,  351 

Mydriasis,  285 

Myoma  of  ciliary  body,  363 

—  of  iris,  326 

Myosarcoma  of  ciliary  body,  363 
Myxoedema,  13 
Myxo-fibroma,  123 
Myxo-lipoma  of  lids,  18 
Myxoma  of  cornea,  258 

—  of  lids,  17 

"  Naevus  cells,"  128 
Nsevus  of  caruncle,  147 

—  of  conjunctiva,  127,  140 

—  of  iris,  322 

-  of  lids,  28 

"  Naevus,"    vascular :    see    Haemangioma, 

Telangiectasis 
Nebula,  167 

"  Necrosis  en  masse,"  222 
Neisser's  stain,  52 
Neurofibromatosis,  13,  17 
Neuroma,  plexiform,  13 
Nicholle's  stain,  46 
Nodular  conjunctivitis,  84 
—  cyclitis,  353 

—  iritis,  292 

-  opacity,  245 

Occlusio  pupillse,  289 
(Edema,  chronic  palpebral,  12 

—  of  conjunctiva,  58 

—  of  cornea,  152,  175,  246 

—  of  epithelium,  175 

25 


386 


INDEX 


(Edema  of  iris,  319 
Ophthalmia  neonatorum,  41,  54 

—  nodosa,  84 
Ossification  in  ciliary  body,  357 

—  in  conjunctiva,  102,  137 

—  in  cyclitis,  346 

—  in  iris,  304 

—  in  sclerotic,  279 

—  in  tarsus,  14 
Osteoma  of  conjunctiva,  137 

—  of  sclerotic,  280 

Pannus,  194 

—  crassus,   siccus,   tenuis,   trachomatosus, 

vasculosus,  197 

—  degenerativus,  196 

—  scrophulosus,  195 
Panophthalmitis,  54,  228,  293,  342 

—  congenital,  53 
Pappenheim's  stain,  56 

Papillae  in  anterior  staphyloma,  170 

—  in  cornea,  168 

—  in  spring  catarrh,  87 

—  of  conjunctiva,  31,  57 
Papilloma  of  caruncle,  146 

—  of  conjunctiva,  118,  143 

—  of  cornea,  256 

—  of  lids,  16 

Parenchymatous  keratitis,  igi,  200,  201 
Parinaud's  lacrymal  conjunctivitis,  38 
Pars  ciliaris  retinae,  335 

—  iridica  retinae,  285 
"  Pearl  "  tumours,  312 
Pemphigus,  89 

-  bacteriology  of,  91 
Perikeratic  hypertrophy,  86 

Peripheral  sclerosis  and  atrophy  of  cornea, 

247 

Phlyctaena  pallida,  86 
Phlyctenular  conjunctivitis,  76 

—  keratitis,  190 
Phosphorus,  tests  for,  235 
Phthiriasis  palpebrarum,  5 
Phthisis  bulbi,  342 

—  congenital,  42 

-  Descemet's  membrane  in,  181 
Pigmentation  of  conjunctiva,  1 10 

—  of  cornea,  no,  249 
Pigment  cells,  i,  128,  140 

—  in  fibroma,  17 

—  in   epithelioma,    146.     See  also  Naevus, 

sarcoma 


Pinguecula,  104 
Plasma  cells,  56 

—  in  trachoma,  70 
Plica  semilunaris,  34 

—  tumours  of,   119,  123,    125,   127,  141, 

147 

Pneumococcus,  36,  jp,  43,  49,  58,  213 
Polypus  of  conjunctiva,  7/7,  122 

—  tubercular,  80 
Posterior  abscess,  210 
Proteid  tests,  241 
Pseudo-diphtheria  bacilli,  51 
Pseudo-gonococcus,  44 
Pseudo-leuksemic  tumours  of  lids,  19 
Pseudo-pterygium,  107 
Pterygium,  106 

Pupillary  membrane,  289 
Pustules  in  conjunctivitis,  57,  77 

"  Randsclerose  und  Randatrophie  der  Horn- 

haut,"  247 

v.  Recklinghausen's  canals,  149 
Regeneration  of  endothelium,  153 

—  of  epithelium,  152 

—  spindles,  189 

Retention  cysts  of  conjunctiva,  112 

—  of  cornea,  254 

—  of  iris,  317 
Reticular  opacity,  247 
Retina,  detached,  181 

—  prolapse  of,  162 
"  Ring  abscess,"  217 
Ring  sarcoma,  372 
Ringworm  of  lids,  8 
Rodent  ulcer  of  caruncle,  147 

—  of  cornea,  222 

—  of  lids,  22 

Sarcoma  of  angle  of  anterior  chamber,  332 

—  of  caruncle,  147 

—  of  ciliary  body,  365 

—  pf  conjunctiva,  129,  138 

—  of  cornea,  259 

—  of  iris,  326 

—  of  lids,  19 

—  of  sclerotic,  281 
Scharlach,  R.,  236 

"  Schimmelpilzkeratitis,"  215 
"  Schwellungskatarrh,"  52 
Scleritis,  271 

—  annular,  273 

—  hyperplastic,  272 


INDEX 


387 


Scleritis,  purulent,  277 
Sclerotic,  cysts  of,  279 

—  degeneration  of,  279 

—  inflammation  of,  270 

—  injuries  of,  267 

—  normal,  266 

—  tumours  of,  280 

—  wounds  of,  267 
Seclusio  pupillse,  289 
Secretion  in  conjunctivitis,  57 
Spaces  of  Fontana,  282 
Sphincter  iridis,  283 

"  Spiessfiguren,"  188,  189 

Spring  catarrh,  86 

Staphylococci,   10,   12,  36,  38,  42,  43,  49,  50, 

77,  91,  r86,  213 
Staphyloma,  anterior,  168 

—  racemose,  168 
Stieda's  folds  and  furrows,  33 
"  Streifenkeratitis,"  179 
Streptococci,  12,  38,  43,  50,  52,  58,  91,  213 
Streptothrix  Forsteri,  74 

Striate  opacity,  179 

Subconjunctivitis,  271 

Sudan  III,  236 

Sulcus  subtarsalis,  30 

"  Sulzige  Infiltration  der  Sclera,"  273 

Syndesmitis  degenerativa,  89 

Synechia,  annular,  289 

—  anterior,  156 

—  posterior,  289 

—  ring,  289 

—  total  posterior,  289 
Syphilis  of  ciliary  body,  354 

—  of  conjunctiva,  78 

—  of  cornea,  191,  igg 

—  of  iris,  294 

—  of  lids,  5 

—  of  sclerotic,  278 
Syringo-adenoma,  27 

Tarsitis  necroticans,  10 

—  syphilitica,  6 
Tarsus,  atrophy  of,  15,  72 

—  calcification  of,  14 

—  hypertrophy  of,  14 

—  in  trachoma,  72 

—  normal,  2 

—  ossification  of,  14 
Tattooing,  253 

Tears,  bactericidal  effect  of,  36 
Telangiectasis  of  conjunctiva,  123 


Telangiectasis  of  lids,  18 

—  of  sclerotic,  280 

Teratoid  tumours  of  caruncle,  147 

—  of  conjunctiva,  135 

—  of  cornea,  258 
Toxins,  action  of,  44,  50 
Trachoma,  59 

—  bacteriology  of,  73 

—  "  corpuscles,"  64 

—  follicle,  60 

—  gelatinous,  71 

—  "  glands,"  60,  69 

—  of  cornea,  197 
Transverse  film,  243 

Traumatic  cysts  of  conjunctiva,  112 

—  of  iris,  312 
Trichiasis,  4 

Tubercle  of  ciliary  body,  356 

—  of  conjunctiva,  79 

—  of  cornea,  199 

—  of  iris,  295 

-  of  lids,  6 

—  of  sclerotic,  278 

Tumours  of  angle  of  anterior  chamber,  331 

—  of  caruncle,  146 

—  of  ciliary  body,  359 

—  of  conjunctiva,  117 

—  of  cornes,  256,  264 

—  of  glands  of  lids,  24 

—  of  iris,  322 

—  of  lids,  15 

—  of  sclerotic,  280 
Tyloma  conjunctivse,  103,  130 
Tylosis,  4 

Ulcer,  atheromatous,  221 

—  chronic  serpiginous,  222 

—  crateriform,  22 

—  hypopyon,  208,  222 

—  internal,  211 

—  marginal,  220 

-  Mooren's,  222 

—  of  cornea,  203 

—  of  sclerotic,  272 

—  rodent,  of  cornea,  222 
—  of  lids,  22 

Ulcus  serpens,  208,  222 
Unna's  stain,  43 

Vascular  fasciculus,  194 
Vernal  catarrh,  86 


388 

Verruca,  16 
Vesicular  catarrh,  57 

—  granulations,  67 

—  keratitis,  175,  if 6 

Vitreous,  adhesion  to  cornea,  156 

—  prolapse  of,  156,  185 

Wart,  1 6 

"  Wimmelzellen,"  74 

Wounds  of  ciliary  body,  336 


INDEX 


Wounds  of  cornea,  complicated,  156 

—  of  cornea,  uncomplicated,  151 

—  of  iris,  286 

—  of  sclerotic,  267 

Xanthelasma,  xanthoma,  9 
Xerodenna  pigmentosum,  119,  146 
Xerosis,  102,  130 

—  bacillus,  12,  35,  50,  51,  gi,  103,  213 

Zonular  opacity,  243 


PRINTED    BY    ADLARD    AND    SON,    LONDON    AND    DORKING, 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


STA'    C 
APR  0  6  1987 
ANNEX 


MARHRECD 


MAR  17 


ANNE-k 


Form  L9-Series  4939 


UC  SOUTHERN  REGIONAL LIBRARY  FACILITY 


A    000  397  843     4 


